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-o'tATE OF CALIFORNIA <br /> REGIONAL WATER (QUALITY CONTROL BOARD <br /> DEPARTMENT OF HEALTH SERVICES <br /> SOLID WASTE MANAGEMENT BOARD SE C� RRA <br /> tl <br /> DEPARTMENT OF FORESTRY <br /> APPLICATION FOR P 0 4 1-In <br /> ENVIRONMENTAL4.4d TtQ <br /> FACILITY PERMIT/WASTE DISCHARGE P E R M?T/3t <br /> This form is to lie used for filinq a/an: (check all appropriate) FOR OFFICE LISE(JNI,V <br /> I REPORT OF WASTE DISCHARGE Form 200 Rec'd <br /> (pittsumni to Division 7 of the SIAM Water Code) Fee IRWOCS) <br /> 2- APPLICATION FOR A HAZARDOUS WASTE FACILITY PERMIT Letter to Discharger__ <br /> (clursunnt 10""Allh and S"(191V Code Section 25200) <br /> 3. APPLICATION FOR A SOLID WASTE FACILITIES PERMIT Report Ree'd <br /> 11pursunnt to Covprmrnpnl Code Section 66796.301 Effective Dst; <br /> 4, rJ APPLICATION FOR A RUBBISH DUMP PERMIT CDF Notified <br /> Ipursuant to Public Resources Code Sections 4371-4375 and 4438) DOHS No. <br /> SWM9 No. <br /> 0. FACILITY <br /> A. NAMIE Or FACILIYV <br /> 0A c_:v_e_ <br /> I..coos <br /> 9. Aw OF LKC AL OWNS A OF FACILITY <br /> -C-0-L-P-C: <br /> essom <br /> C. Amu or nusissuss oPscxA7vjt;sj FAC11.14-y-, <br /> alp Cova <br /> F <br /> Sole Proprietorship Partnership Corporation Government Agency <br /> F. NA1641i-o"OWHi" 9 OW BTU 1499s 6A7rT'4G iAE UFi <br /> all COOL ' <br /> 7 <br /> It. iTO�;O" FOR 1`11-1-40 <br /> ALL <br /> A. N dirharpr or facilitV D. Change in character of discharge G. Change In business operating facility <br /> New <br /> H. <br /> itfinst'jichnrop.of fnCility E. Change in piece or method of disposal H. Enlargement of existing facility <br /> C. <br /> EIncrease in quantity of dischnrqe F. Change in design or operation 1. Other lexplain below) <br /> Ill. TYPIE OF OPERATION <br /> 111— ALL A-MOV-11: <br /> A. Transfer slotion D. Sewage treatment G. Woodwaste site <br /> n. Solid waste disposal site E. <br /> Industry(on-sitedisposalfacility) H. Other(explain below) <br /> C. Hazardous waste disposal site F. Industry(discharge to sewer) <br /> IV. TYPE Or WASTE <br /> CI*Cft ALL APPROP01.10: <br /> A. S01whal <br /> shirion,and/or <br /> snptic t6 <br /> nk ptimpinsis Industrial wastes F E AgrIcu ural wastes I. Inert materials <br /> n E. <br /> Animal westos J. Deed animals <br /> C. Municipal solid wnstrs G. Forest product wastes K. Tires <br /> D. Hazardous wastes K Construction/demolition wastes L. <br /> Other(explain below) <br /> V. SITE DRSIGH CAPACITY <br /> ........... rr,06#00"POPULAI"O.0.U1.1161.18 C.PA. 9 EXPECT^kCV lvm^ftol <br /> LQ <br /> Pon" too (.ay. 9/80) (OVER) <br />