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State of California CIWMB 169 (Rev 4/04) • • ENFORCEMENT AGENCY NOTIFICATION California Integrated Waste Management Board Enforcement Agency: Official Use Only SWIS Number: County: Date Received: I. GENERAL INFORMATION Operation Name: yP _rLpmt s as IT Address: P. 0, o2 4, L,13 City: IA n o n CL State: cps Zip: q4 Phone: 5112-11to_ 0 q I Fax: ,�— ru nT LZZ o u -T c.uv I:!. . co Operator Name: o E2 Address: I 20SVO He LLY d 2 City: jLq r--/ State: e -p Zip: �jS3 0 Phone: 0 _ Q VL7 Fax: Land Owner: Address: City: State: Zip: Phone: Fax: II. OPERATION INFORMATION Authorizing Eligibility (State Section of 14 CCR Division 7, Chapter 3 or 3.1): See back for more details Type(s) of Waste/Material Handled: QEEN VyA95r9 Wo o Z> Volume of Waste/Material Handled: Peak Loading: ❑ Cubic Yards or ❑ Tons Annual Loading: ❑ Cubic Yards or ❑ Tons Days and Hours of Operation: o,v064 ��Sp A MRany Operation Acreage: Jq Brief Description of the Operation: I q _ /1 s. 3`fs L I&J&57vs o -n 6.E 5 1-oC44 ►/I n I Cn cl 54J e f W&S t -t CA -5 YV G4[.is l 6)1ti Q- S 0 CX L 1142- e c it�—e5AJ 774e,.j %letup vG l e C_e t %) 2 O o D P 5 u2 E E'N 7He,^J f?Gj-[v UE C-►r2EENI Sc.)ZECA/CD F/AfES W ►c.- A3.= s7VcA-_ ei/eco a- t*0" Pasf--CiJ . III. DOCUMENTATION OF LOCAL NOTIFICATION (check one and submit with EA Notification) ❑ Proof of Compliance with the California Environmental Quality Act (CEQA). ❑ Correspondence from the local planning department that compliance with CEQA is not required for the operation to obtain local land use approval. Written notice to the local planning department of the operator's intent to commence operations. IV. OWNERIOPERATOR CERTIFICATION I hereby certify under penalty of perjury that the information provided is true and accurate to the best of my knowledge and belief. Signature of Land Owner: Date: Signature of Operator: Date: Completion of this form is not required by regulation; however, it will provide the enforcement agency with the information required by 14 CCR 18103.1. 0 A separate Notification is required for each eligible operation.