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State of California California Integrated Waste <br /> CIWMB 169(Rev 4/04) Management Board <br /> ENFORCEMENT AGENCY NOTIFICATION <br /> 'Enforcement Agency: Official UseOnly <br /> SWIS Number: <br /> County: Date Received: <br /> GENERAL INFORMATION <br /> Operation Name: tsr_ <br /> Address; I Z& 7 p a13 raZ4g�ti City: State; Go -' r " 5 <br /> Phone Z o <br /> Operator Name: <br /> Address: ` Ctty °:; State: <br /> Phone: Fax: <br /> Land Owner: <br /> Address: r City: State: zip <br /> Phone: Faz: <br /> II. OPERATION INFORMATION <br /> Authorizing Eligibility(State Section of 14 CCR Division 7,Chapter 3 or 3.1):See back for more details <br /> Type(s)of Waste/Material Handled: Cf V <br /> Volume of Waste/Material Handled: j _.Ve <br /> Peak Loading: I z, Cubic Yards or ❑Tons Annual Loading: 7 C i Cubic Yards or ❑Tons <br /> Days and Hours of Operation: Operation Acreage: <br /> Brief Description of the Operation: <br /> S 7i a Ck <br /> T11 Gee — <br /> t' -o 7 Q <br /> lll. DOCUMENTATION OF LQCAL NOTIFICATION (check one and submit with EA,Notificaton) <br /> ❑ Proof of Compliance with the California Environmental Quality Act(CEQA). <br /> El obtain <br /> from the local planning department that compliance with CEQA is not required for the'operation to <br /> obtain local land use approval. <br /> ❑ Written notice to the local planning"department of the operator's intent to commence operations. <br /> W.","OWNER/OPERATOR CERTIFICATION` <br /> 1 hereby certify under penalty of perjury that the information provid true and accurate to the best of my knowledge and belief. <br /> Signature of Land Owner: �/,� , �" Date. <br /> Signature of Operator: Date: <br /> *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. <br /> 0 A separate Notification is required for each eligible operation. <br />