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State of California CalRecycle 169 (Rev. 12/17) Department of Resources Recycling and Recovery (CalRecycle) ENFORCEMENT AGENCY NOTIFICATION Enforcement Agency: wmpieuun ui nus loon Is nm required by regmaoort; However, irwui provide the enforcement agency with the Official Use Only SWIS Number: County: Date Received: L GENERAL INFORMATION Operation Name: D fYl Address: �t4ffS Phone: Fax: City: State: Zip: Operator Name: 7p 0 Address: I Phone: 2( . (D, _ I -71- Fax: City: State: '� Zip: Land Owner: 141 .. v ) - o Address: 5fi Phone: � el _ U • Fax: City: C� State: Zip: G II. OPERATION INFORMATION tluthorizing Eligibility (State Section of 14 CCR Division 7, Chapter 3, 3.1 or 33): See back for more 179 5 Type(s) of Waste/Material Handled: vAanur'Q lr/len LULLS co -min tog Volume of Waste/Material Handled: -1 pee) w ar S Peak Loading: OCubic Yards orUpTops Annual Loading: i❑pCubic Yards or©Tons Days and Hours of Operation: �AYYI _ l� h1 Operation Acreage" Brief Description of the Operation: gtta� o f e l �t CD -mm III, DOCUMENTATION OF LOCAL NOTIFICATION (check one and subi nit 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. OWNERIOPERATOR CERTIFICATION Ihereby certify under penally of perjury that the information provided is true and accurate to the best of my knowledge and belief. Signature of Land Owner: Signature of Operator: Date: Date: 5 z r, 2 information required by 14 CCR 18103.1. • A separate Notification is required for each eligible operation. Please cite only one of the following Title 14 regulations when filling in the "authorizing eligibility" box of Notification Farm CalRecycle 169: