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State of California California Integrated Waste COMB 169 (Rev 4/04) Management Board ENFORCEMENT AGENCY NOTIFICATION Enforcement Agency: Official Use Only SWIS Number: County: Date Received: I. GENERAL INFORMATION Operation Name: yf�rttsE Address: p 0,ili,0 Y 2& 3 City: tOr1 State: Cpt Zip: yj- Phone: _ _ 0 Fax: ,z� r i nT z o LLT Luo V_ - cu rn Operator Name: ,. ovE!r ol Address: ZpSra He LLY da_ City: i2fFt�/ State: I to I Zip: I qS-3 v Phone: sic _ o _ 77 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 8 L Z , Type(s) of Waste/Material Handled: &&Ew VVJ95r& Wo o Volume of Waste/Material Handled: Peak Loading: ❑ Cubic Yards or El ons Annual Loading: T ❑ Cubic Yards or ❑ Tons Days and Hours of Operation: cNuA4—dSAruMp„y Operation Acreage: 1 Brief Description of the Operation: I q _ 11 s, 3Y L &57Us o-„ t.e 0 s tro &4e_ 11,r nel &,J cl 541-e -r lc &S C ro G4LfSbnC in e e 6 n L ,. S e, L• e D c OU545 J f aE'.n40 AIG I ec-e WOO p> .4 P $u2EEA! 7746^J RojgcU6 C,Qe,eAt i=tIVES U)iid— 6—= STvc,t--etlet> a- 40"4PaS1-sto . 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. OWNER/OPERATOR 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: T Date: Signature of Operator: Date: Lf � I 1 * 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.