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State of California CIWMB 169 (Rev 4/04) ENFORCEMENT AGENCY NOTIFICATION California Integrated Waste Management Board Enforcement Agency: I. GENERAL INFORMATION Official Use Only SWIS Number: Address: County: A d/_ Date Received: L IgeV Completion of this form is not required by regulation; however, ilwill provide the enforcement agency with the Information required by 14 CCR 18103.1. 0 A separate Notification is required for I. GENERAL INFORMATION Operation Name: Address: I Z,3 7 p V 13 raaelr A d/_ City: L IgeV I State: I C ,FZip q S yj Phone: 1209 703_06Y2. Fax: Zo V_ 96 �g V116 Operator Name: Address: City: State: Zip: Phone: Fax: Land Owner: Address: City: State: I 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 WastelMaterial Handled: yCf` t vP� Volume of Waste/Material Handled: t^ x Peak Loading:2,0 CubicYardsm0Tons I Annual Loading: 70/yo CubicYardsorE]Tons Days and Hours of Operation: {p Operation Acreage: Brief Description of the Operation: rpt bre f1 e o 7 Fova7"7:22oe d,,4,gC4V;V .021, 7o &2 dxv 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 cedily under penalty of perjury that the information provide true and accurate to the best of my knowledge and belief. Signature of Land Owner: Date: eeee� /` ,_0 it Signature of Operator: Date: each eligible operation.