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STATE OF CALIFORNIA <br />CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD <br />REGIONAL WATER QUALITY CONTROL BOARD <br />APPLICATION FOR SOLID WASTE FACILITY PERMITIWASTE DISCHARGE REQUIREMENTS <br />CIWMB E-1-77 (Rev. 8-04) <br />NOTE: This form has been developed for multiple uses. It is the transmittal sheet for documents required to be submitted to the appropriate agency. <br />Please refer to the attached instructions for definitions of terms and for completing this application form in a complete and correct manner. <br />FOR OFFICIAL USE ONLY <br />SWIS NUMBER: <br />FILING FEE: <br />RECEIPT NUMBER: <br />DATE RECEIVED: <br />DATE ACCEPTED: <br />DATE REJECTED: <br />ACCEPTANCE DATE OF <br />INCOMPLETE APPLICATION: <br />DATE DUE: <br />Part 1. GENERAL INFORMATION <br />A. ENFORCEMENT AGENCY: <br />one <br />1. NEW SWFP and/or WDRS <br />02. REVISION OF SWFP and/or WDRS <br />B. COUNTY: <br />F14. PERMIT REVIEW <br />5. AMENDMENT OF APPLICATION <br />113. EXEMPTION and/or WAIVER ❑6. RFI/ROWD/JTD AMENDMENTS <br />Part 2. FACILITY DESCRIPTION <br />A. NAME OF FACILITY: <br />B. LOCATION OF FACILITY: <br />1. PHYSICAL ADDRESS OR LOCATION AND ZIP CODE: <br />2. LATITUDE AND LONGITUDE: <br />3. LEGAL DESCRIPTION OF PERMITTED BOUNDARY BY SECTION, TOWNSHIP, RANGE, BASE, AND MERIDIAN, IF SURVEYED: <br />C. TYPE OF ACTIVITY: (Check applicable boxes): <br />01. DISPOSAL M3. TRANSFORMATION ❑5. OTHER (describe): <br />a. TYPE: <br />❑2. COMPOSTING <br />a. TYPE: <br />®4. TRANSFER/PROCESSING FACILITY <br />❑ CHECK HERE IF RECYCLABLE MATERIALS ARE RECOVERED PRIOR TO TRANSFERIPROCESSING. <br />D. CONFORMANCE FINDING INFORMATION (CIWMP): <br />01. FACILITY IS IDENTIFIED IN (Check one): <br />SITING ELEMENT <br />®NONDISPOSAL FACILITY EL <br />DATE OF DOCUMENT <br />DATE OF DOCUMENT <br />112. FACILITY IS NOT REQUIRED TO BE IDENTIFIED IN SITING ELEMENT OR NONDISPOSAL FACILITY ELEMENT <br />E. TYPE OF PERMITTED WASTES TO BE RECEIVED: (Check applicable boxes): <br />F-11. AGRICULTURAL <br />®2. ASBESTOS ❑ Friable O Non -friable <br />❑3. ASH <br />1:14. AUTO SHREDDER <br />05. COMPOSTABLE MATERIAL (describe): <br />E-16. CONSTRUCTION/DEMOLITION <br />F-17. CONTAMINATED SOILS <br />F-1 B. DEAD ANIMALS <br />E-19. INDUSTRIAL <br />E-110. INERT <br />M11. LIQUIDS <br />®12. MIXED/MUNICIPAL SOLID WASTE <br />M13. SEWAGE SLUDGE <br />14. TIRES <br />[:]15. OTHER (describe): <br />PAGE # <br />PAGE # <br />Page 1 <br />