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Appendix 1 Joint Permit Application Form

27 CA ADC Div. 2 Subd. 1 App. 1Barclays Official California Code of Regulations

Barclays California Code of Regulations
Title 27. Environmental Protection
Division 2. Solid Waste (Refs & Annos)
Subdivision 1. Consolidated Regulations for Treatment, Storage, Processing or Disposal of Solid Waste
Chapter 8. Other Provisions
Subchapter 1. Financial Assistance Programs
27 CCR Div. 2 Subd. 1 App. 1
Appendix 1 Joint Permit Application Form
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR SOLID WASTE FACILITY PERMIT AND WASTE DISCHARGE REQUIREMENTS
 
This application form is for a Solid Waste Facility Permit (SWFP) and/or Waste Discharge Requirements (WDRs) to receive, store, process, transform, or dispose of solid waste regulated by the Department of Resources Recycling and Recovery (CalRecycle) and Enforcement Agencies (EAs) or California Regional Water Quality Control Boards (RWQCBs), and for related purposes. The Application is to be used for new and changes to existing SWFPs, WDRs, and supporting documents (e.g. Reports of Facility Information, Reports of Waste Discharge), and for SWFP Reviews. AN Applications must be filled out completely and correctly. Check with the applicable EA or RWQCB for specific permit requirements and exemptions or the use of the Application/General Information Form for WDRs and National Pollutant Discharge Elimination System permit (Form 200) by the RWQCB. Submit the Application and filing fees to the appropriate agency(ies) indicated below:
FORM TYPE / USE
APPROPRIATE AGENCY
Application for a Solid Waste Facility Permit
EA
Report of Waste Discharge for WDRs
RWQCB
If you have any questions on how to complete this form, please contact the appropriate agency(ies) for assistance. You can download this form from the CalRecycle website at http://www.calrecycle.ca.gov.
NOTE: For direct discharge (point source discharge) to surface waters, a different application form and submittal package is required. Please contact the appropriate RWQCB if seeking to discharge to surface water under the NPDES permit.
Submit two copies of the completed Application and filing fee to the EA. Submit one copy of the Application to the RWQCB. The RWQCB will notify you of your annual fee based on an evaluation of your proposed discharge. Please do not submit a check to the RWQCB until requested to do so by a RWQCB representative. Applicants applying for an update of an existing WDR will be billed through the annual fee billing system and therefore are requested NOT to submit a check with their Application. The agency(ies) will advise you of any additional information that may be required to complete this Application.
The Applicant shall submit this Application in a form and format required by the EA. The EA will exercise its discretion in using the information provided by the Applicant to establish terms and conditions of a proposed SWFP the EA determines to be appropriate.
 
AMOUNT OF FILING FEES
• EA - Contact the EA for fee information.
• RWQCB - Contact the RWQCB for fee information.
 
FOR OFFICIAL USE ONLY (CalRecycle/EA/RWQCB staff)
SWIS/WDID/Global ID Number: The Solid Waste Information System (SWIS) number assigned to the facility by CalRecycle staff. The Waste Discharge Identification number (WDID) and global identification number (global ID) for use by RWQB staff.
Filing Fee: The amount of filing fee submitted by the applicant.
Receipt Number: The number assigned to the Application by CalRecycle/EA/RWQCB staff.
Date Received: The date the EA or RWQCB receives the Application from the applicant (Title 27, section 21650(a)).
Date Accepted: The date the EA accepts the Application for filing (Title 27, section 21650(a)). Leave blank if the Application is for a SWFP review (Title 27, section 21640).
Date Rejected: The date the EA rejects the Application (Title 27, section 21650(d)). Leave blank if the Application is for a SWFP review (Title 27, section 21640).
Date of Acceptance of Incomplete Application: The date the EA accepts an incomplete Application (Title 27, section 21580). Date Due: Within 180 days from the date the application was accepted as incomplete (Title 27, section 21580). Leave blank if Application is for a SWFP review (Title 27, section 21640).
 
Part 1. GENERAL INFORMATION
A. Enforcement Agency: Enter the name of the EA.
B. County: Enter the name of the county or counties in which the facility is located.
C. Type of Application: Check the box (one box only) that describes the reason the Application is being submitted, as follows:
1. New SWFP and/or WDRs: A facility that does not have a current SWFP or WDRs.
2. Change to SWFP and/or WDRs: Applicant is proposing to make a change to the design or operation of the facility. (Title 27, section 21620 and 21710)
3. Waiver: WDRs have been waived.
4. Review: To comply with the five-year permit review requirement (Title 27, section 21640).
5. Amendment of Application: If the applicant changes any of the information required in the Application after it has been submitted and before the EA has acted on the Application. (Title 27, section 21610 and 21710)
6. RFI/ROWD/JTD Amendments: A change to the Report of Facility Information, Report of Waste Discharge, or Joint Technical Document that does not require a change to the SWFP or WDRs.
 
Part 2. FACILITY DESCRIPTION
A. Name of Facility: The name to be listed on the SWFP and/or the WDRs.
B. Location of Facility:
1. The physical address of the facility or, if no address, a description of the location. Include the Assessor's Parcel Number, directions to the location of the facility and the name of the nearest city or named place, i.e. mountain, lake, cross roads, etc. Provide the zip code for the actual facility location, not the mailing address.
2. Latitude and longitude in Degrees, Minutes, and Seconds, or Decimal Degrees identifying the center of the waste footprint for existing or proposed disposal sites and identifying the office or main gate for all other facilities (e.g., transfer station, composting facility, etc.). Use of a GPS instrument is recommended.
3. The legal description shall include the applicable portions of the section(s) of the township, range, base, and meridian. The facility shall have permanent monuments or other physical features that adequately delineate the permitted boundary in the field.
C. Type Of Activity: Check all that apply or will apply for the type of facility covered under this Application.
1. Disposal: A facility that includes a place, location, tract of land, area, or premises in use, intended to be used, or which has been used, for landfill disposal of solid waste.
a. Type: The type of disposal facility, such as, monofill, C&D/inert, municipal solid waste, or Engineered municipal solid waste conversion facility.
2. Compostable Material Handling: A facility that handles compostable materials.
3. Transformation: A facility at which solid waste is incinerated or subject to pyrolysis, distillation, or biological conversion other than composting. Transformation does not include composting, gasification, or biomass conversion.
4. Transfer/Processing: A facility that receives, handles, stores, separates, converts or otherwise processes solid waste or transfers solid waste directly from one container to another or from one vehicle to another for transport.
5. Construction and Demolition/Inert Debris Processing: A facility that receives Construction and Demolition Debris and/or Inert Debris for the purpose of controlled separation, recovery, volume reduction, or recycling.
6. In-vessel Digestion: A facility that receives solid waste for digestion in an in-vessel digester.
7. Other: An activity authorized by law not listed above.
D. Identification of Facility in CIWMP [Conformance Finding Information] (Title 27, section 21570(f)(5)):
1. If the location of the facility is identified in either a Countywide Siting Element or a Nondisposal Facility Element, check the appropriate box, and fill in the date of the document and the page on which the facility is identified. (You may obtain this information from the jurisdiction in which the facility is located).
E. Type Of Permitted Wastes To Be Received: Check all that apply for the type of material covered under this Application package:
1. Agricultural: Wastes resulting directly from the conduct of agricultural activities, including, but not limited to, manures, prunings, and crop residues.
2. Asbestos: The State Department of Toxic Substances Control classifies friable wastes which contain one percent or more asbestos by weight as hazardous wastes. Friable means that the material can be crumbled with pressure and, therefore, is likely to emit fibers. Indicate whether the asbestos is friable or non-friable by checking the appropriate box.
3. Ash: The residue from the incineration of solid wastes, including, but not limited to, municipal waste, medical waste, woodwaste, sludge, and agricultural waste.
4. Treated Auto Shredder Waste: The “fluff” consisting of upholstery, paint, plastics, and other non-metallic substances that remains after the shredding of automobiles, discarded household major appliances, and similar items.
5. Compostable Material: Any organic material that when accumulated will become active compost. Describe the types of compostable materials to be received.
6. Construction/Demolition Waste: Waste that results from construction, remodeling, repair, demolition or deconstruction of buildings, and other structures.
7. Contaminated Soil: Soil that the RWQCB or the Local Oversight Agency has classified as a designated waste.
8. Dead Animals: Animal carcasses requiring disposal that have not been previously used for medical purposes and are not known to have been infected with infectious diseases.
9. Industrial: Solid or semi-solid wastes resulting from industrial processes and manufacturing operations, e.g. cement kiln dust, ore process residues, grit or screenings removed from a waste water treatment facility, etc.
10. Inert: Solid waste and recyclable materials that are source separated or separated for reuse, do not contain hazardous waste or soluble pollutants at concentrations in excess of applicable water quality objectives and do not contain significant quantities of decomposable waste. Inert debris may not contain more than 1% putrescible wastes by volume calculated on a monthly basis and the putrescible wastes do not constitute a nuisance, as determined by the EA.
11. Liquids: Wastes which are not spadable, usually containing less than 50% solids. These wastes include cannery and food processing wastes, landfill leachate and gas condensate, boiler blowdown water, grease trap pumpings, oil and geothermal field wastes, septic tank pumpings, rendering plant byproducts, some sewage sludge, etc.
12. Municipal Solid Waste (MSW): Solid waste generated primarily by residential and commercial sources, although it may contain insignificant amounts of other solid waste that, when mixed together, is all handled as MSW.
13. Sewage Sludge: Human (not industrial) residue, excluding grit or screenings, removed from a wastewater treatment facility or septic tank, whether in a dry or semidry form.
14. Waste Tires: Tires that are no longer mounted on a vehicle and are no longer suitable for use as a vehicle tire due to wear, damage, or deviation from the manufacturer's original specifications including, repairable tires, scrap tires, altered tires, and used tires that are not organized for inspection in a rack or a stack.
15. Other: Any allowable wastes not included in the above.
 
Part 3. FACILITY INFORMATION
A. Facility Information
1. Information Applicable To All Existing Facilities: This portion of the Application must be filled out by every applicant regardless of the type of facility.
a. Maximum Daily Tonnage or Cubic Yards: The maximum amount of solid waste and other material the applicant is authorized by the EA to receive through the gate per day as part of normal, day-to-day operations (include information on all other material authorized by the EA to receive in the Report of Facility Information (RFI)). This amount shall be expressed in tons; if tonnage is not available specify the amount in cubic yards with a conversion factor. This amount must be consistent with the approved SWFP and the approved RFI. Applicants for new SWFP and/or WDRs enter zeros (0) in all items of this section. Note: The two amounts in (1) and (2) below must equal the maximum daily tonnage.
1. Disposal/Transfer: The amount of solid waste that comes through the gate and is disposed of on-site or transferred off-site as waste; and
2. Other: That amount of all other material received at the site, including, but not limited to, material that is recycled, beneficially reused (such as ADC, road building or other on-site projects), stored or processed.
b. As-Designed Daily Tonnage or Cubic Yards: For landfills, the maximum amount of solid waste and other material that the facility is designed to receive and process on an ongoing basis over an extended period of time (e.g., on a daily basis over a calendar month) based on appropriate factors including, but not limited to, size of the operating areas, vehicle traffic, hours of operation, personnel, equipment operational limits, etc. For other facilities, the maximum amount of solid waste and other material the facility is designed to receive and process on an ongoing bases over an extended period of time (e.g., on a daily basis over a calendar month) based on appropriate factors including, but not limited to, vehicle traffic, facility size, hours of operations, length of material storage, type of equipment and movement, personnel, equipment operational limits, etc. This amount shall be expressed in tons; if tonnage is not available specify the amount in cubic yards with a conversion factor. The as designed value may be equal to or greater than the maximum daily value.
c. Facility Size: The area that encompasses the entire area on which solid waste facility activities are authorized by the EA to occur. This includes the area of the facility in acres to be used for specific purposes such as receiving, storing, processing, disposing of wastes, and managing equipment, or any area that is required to maintain compliance with the design and operating parameters of the facility. The facility size is the same as “operating area” for compostable material handling facilities, “permitted acreage” or the area within the “permitted boundary” for transfer/processing facilities and landfills.
d. Maximum Traffic Volume Per Day (vpd): The maximum number of vehicles authorized by the EA to enter the facility on a daily basis. This number includes all vehicles, laden or empty, entering the facility gate, including vehicles transporting solid waste, personnel vehicles and vehicles transporting cover material or material intended for beneficial reuse. This number must be consistent with the approved RFI.
e. Days and Hours of Operation: The days and hours that the facility is authorized by the EA to operate and the hours of waste receipt authorized by the EA if different from the hours of operation. This information must be consistent with the approved RFI. Any activities that are limited to prescribed days or hours should be fully described in the RFI.
2. Proposed Change(s) or Information Applicable to New SWFP and/or WDRs: This portion of the Application must be filled out by every applicant requesting a change to any item(s) listed under Part 3. A. 1 and every applicant submitting an application for a new SWFP and/or WDRs (see Part 3.A.1. for a description of the terms used). The requests must be consistent with an RFI submitted as part of the Application. The EA will review the requests and establish the terms and conditions of a proposed SWFP for those requests that are supported by documents submitted by the applicant. The RWQCB will review the requests and establish the terms and conditions of tentative WDRs for those requests that are supported by documents submitted by the applicant. Use the “OTHER” section to describe design or operational requests not already specified in this Part 3.A.2.
3. Additional Information Required For Compostable Materials Handling Facilities Only: This portion of the Application must be filled out by the applicant if handling compostable materials is part of this Application.
a. Total Site Capacity: The total capacity in tons or cubic yards of all material that is received, processed, and stored on-site at any one time.
4. Additional Information Required For Landfills Only: This portion of the Application must be filled out by the applicant if a landfill is part of the Application. All sections of the Application must be filled out completely.
a. Average Daily Tonnage (TPD): The estimated average waste tonnage expected to be placed in a waste management unit for each operating day on a yearly basis (calendar year) for the next five years. Do not use non-operating days in calculating the average daily tonnage. This average daily tonnage can be equal to but may not exceed the maximum daily tonnage. Report as tons per day (TPD).
b. Site Capacity Currently Permitted (Airspace) (cu yds): The volume contained between the excavation plan surface and the final fill plan surface (i.e., from the bottom of the excavation to the top of the final cover) taking into consideration design slopes, benches, and other design features, as authorized by the current SWFP. Site Capacity means the same as Total Site Capacity or Gross Site Capacity.
c. Site Capacity Proposed (Airspace) (cu yds): Additional site capacity (airspace) requested or potentially resulting from this permit Application.
d. Site Capacity Used To Date (Airspace) (cu yds): The volume of permitted site capacity used to date. See Date of Capacity Information below.
e. Site Capacity Remaining (Airspace) (cu yds): The total volume of permitted site capacity remaining, not including any proposed site capacity. If the remaining capacity information provided is based on estimates of capacity used since the last physical site survey, please explain the methodology used in preparing the estimates, e.g., weight-to-volume conversion, in-truck volume, etc. See Date of Capacity Information below.
f. Date Of Capacity Information (date): The date as of which the remaining and used site capacities in Part 3 were determined. This date may predate the Application date by no more than three months. Amendments of the Application including more current capacities may be required.
g. Last Physical Site Survey (date): Date when the last aerial or ground survey was conducted upon which the capacity information presented in Part 3 is based in whole or in part. (see Part 6, Section B for more details).
h. Estimated Closure Date (month and year): The closure date estimated based on remaining waste capacity, average disposal volume, waste-to-cover ratio, days of operation, and other appropriate factors. Please note if the closure date is controlled by factors other than waste capacity (e.g., conditional use permit date, etc.)
i. Disposal Footprint (acres): The permitted area where waste will be or has been placed. This will be referred to as “permitted disposal area.”
j. Site Capacity Planned (cu yds): The estimated additional site capacity (in cubic yards) based upon any planned expansions not currently proposed, whether within or outside the current permitted boundary.
k. Provide one of the following:
1. (i) In-place Waste Density (lbs of waste per cubic yard of waste). The in-place waste density is the estimated or measured density of in-place waste material achieved by mechanical or other means in the development of the current lift of the current operating waste cell, and
(ii) Waste-to-Cover Ratio (estimated) (volume:volume). The waste-to-cover ratio estimate is a unit-less expression of the proportion of the volumes of waste and cover that comprise a volume of compacted fill material, e.g. 4:1. The cover portion of the waste-to-cover ratio estimate should include only soil or approved daily or intermediate alternative cover that is not considered a waste material, i.e., payment of fees to CalRecycle is not required. The waste portion of the waste-to-cover ratio estimate should include only waste material for which payment of fees to CalRecycle is reported, or
2. Airspace Utilization Factor (tons of waste per cubic yard of landfill airspace). The airspace utilization factor (AUF) is the effective density of waste material in the landfill. The AUF is recorded as the total weight of waste material passing over the landfill scales that is placed in a known volume of landfill airspace in a given period of time. The waste portion of the AUF should include only waste material for which payment of fees to CalRecycle is reported.
 
Part 4. SOURCE OF WATER SUPPLY (This is water used for any purpose at the facility)
A. Municipal or Utility Service: Give name and address of the water purveyor.
B. Individual Wells: Identify those wells that are not part of a municipal or utility service.
C. Surface Supply:
1. Provide the name of any stream, lake, spring, etc, if identified.
2. Type of water rights: Check appropriate box to indicate riparian or appropriation.
3. If a state permit or license has been granted, give identification number.
D. Other: Enter any water source(s) not identified above.
 
Part 5. COMPLIANCE WITH CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA)
A. Check the appropriate box(es) if an environmental document was, or will be, prepared and circulated through the State Clearinghouse (SCH) to comply with the requirements of CEQA.
1. If an environmental document was prepared:
• If an environmental document has already been prepared and circulated through the SCH and there is a SCH number, please write this number in the appropriate blank following the box that is checked.
• If an environmental document has not yet been circulated through the SCH and no SCH number has been assigned to the environmental document yet, please check the box for the type of environmental document that is anticipated to be circulated through the SCH and write N/A in the appropriate blank for “SCH#.”
• If the “ADDENDUM TO (Identify environmental document)” box is checked, please provide the type of environmental document that the addendum was prepared for along with the SCH number.
2. If an environmental document will be prepared, enter the name of the lead agency for preparing the document, if known.
EXAMPLE ONLY:
If the environmental document is an environmental impact report (EIR), write “EIR” and include the dates that the EIR was circulated (i.e. from what date to what date). Also, please provide the SCH number for the EIR.
B. If an environmental document was not, and is not planned to be, prepared because it is not required to comply with the requirements of CEQA, please provide the requested information by checking the box to indicate why an environmental document is not required under CEQA.
• If the “CATEGORICAL/STATUTORY EXEMPTION (CE/SE)” box is checked, please provide the CEQA Guidelines Section number and citation for the exemption.
EXAMPLE ONLY:
A class I categorical exemption from the requirements of CEQA might be cited in the case of a minor repair to an existing facility. Therefore, check the box that says “CATEGORICAL/STATUTORY EXEMPTION (CE/SE)” and write the following in the blank after the box: “CEQA Guidelines, Section 15301, Class I Categorical Exemption.”
 
Part 6. LIST OF ATTACHMENTS (Fill in the date for each document checked)
All attachments are necessary parts of the Application and are incorporated herein.
A. Section A must be completed by all applicants regardless of the type of facility.
B. Section B must be completed only by applicants for disposal facilities.
• Operating Liability Financial Mechanism: The date the demonstration was last modified or renewed. That date must be within the preceding twelve-month (annual renewal) period. For example, a Certificate of Insurance (CalRecycle 107) has an “effective date” identified on the certificate and must be within the preceding twelve-month (annual renewal) period.
• Financial Responsibility Documentation: The financial mechanism is a document, (i.e., letter of credit, surety bond, trust fund statement of value, enterprise fund value (balance) statement, etc.) identifying the current dollar value of the demonstration and the date of the stated value. The date of the stated value must be within the preceding twelve-month (annual renewal) period.
• Closure/Post Closure Maintenance Plan: The closure and postclosure maintenance plans are those plans required by Title 27, sections 21780 and 21865 as applicable.
• Known or Reasonably Foreseeable Corrective Action Cost Estimates: A copy of the water release corrective action cost estimate and a copy of the non-water release corrective action cost estimate, as required by Title 27, sections 22100 through 22103.
• Landfill Capacity Survey Results: For disposal facilities permitted to receive more than 20 tons per day, a ground or aerial survey is to be prepared at least every five years or more frequently as determined by the EA. For disposal facilities permitted to receive 20 tons per day or less, a ground or aerial survey must be prepared at least once every ten years. If not previously submitted, survey results must be included with this Application. Survey results must be submitted as a CADD or vector graphics data file including at least two strata, i.e., 1) a stratum showing the base and finished ground surfaces, and 2) a stratum showing the existing and finished ground surfaces. For disposal sites where a change in permitted volume is proposed, a third stratum showing the base and proposed finished ground surfaces must be included. For each stratum the following information shall be included: site name, stratum name, surfacel name, surface2 name, volume calculation method (grid, composite, section), expansion (cut) factor, compaction (fill) factor, cut volume, fill volume and net volume. All volumes shall be reported in cubic yards. (Title 27, section 21570(f)(10)). If the base ground surface is uncertain, the operator is allowed to provide the best available information as a substitute for the actual as-built contours. If selecting this substitute method, the operator must provide an explanation of the basis for using the substitute base ground surface.
For the purposes of this section the following definitions apply:
1. “base ground surface” - the best available excavation plan surface that existed prior to the placement of any waste;
2. “CADD” - computer aided design and drafting;
3. “compaction (fill) factor” - the factor used to correct for expected compaction of fill material; this factor should normally be unity (one); if the factor is not unity (one), an explanation must be provided for the basis of the volumetric correction;
4. “cut volume” - for any stratum, the volume removed by a cut of a lower surface to achieve the upper surface;
5. “existing ground surface” - the topography that exists at the time of the subject survey;
6. “expansion (cut) factor” - the factor used to correct for expected expansion of a cut surface; this factor should normally be unity (one); if the factor is not unity (one), an explanation must be provided for the basis of the volumetric correction;
7. “fill volume” - for any stratum, the volume bound between the upper and lower surfaces;
8. “finished ground surface” - the final fill plan surface as shown in the approved closure plan for the disposal site;
9. “net volume” - the fill volume less the cut volume;
10. “site name” - the name of the disposal site for which the survey information is being submitted;
11. “stratum (plural: strata)” - a particular volume of a solid waste landfill bound by specified upper and lower surfaces;
12. “stratum name” - a descriptive name for the stratum for which volumetric information is being submitted, e.g., total volume including proposed expansion;
13. “surface names” - names for the pair of surfaces that define a named stratum, e.g., base ground surface and proposed finished ground surface;
14. “survey” - a comprehensive examination of the disposal site under the direction of a registered civil engineer or a licensed land surveyor for purposes of determining the topography of the base, existing and finished ground surfaces, and the volumes bound by those surfaces;
15. “vector graphics” - computer generated images comprised of lines and shapes of given origin, direction, thickness, color and other attributes;
16. “volume calculation method” - grid, composite, section or other method approved by the EA.
C. Section C specifies additional documents required for the type of facility to be covered under this Application as required by the EA or RWQCB. Under “Other,” identify and list any other necessary documents not specified above but that are required by the EA or RWCB under applicable law, such as, a lease or other agreement documenting the operator's interest in and right to use the site as a solid waste facility or a contract between the permitted operator and contract operator.
 
Part 7. OWNER INFORMATION:
Type of Business: Specify if the owner of the facility that is the subject of the Application is a sole proprietorship, partnership, corporation, or public agency.
Owner of Land: The person(s) that owns the land on which the facility is located.
Address, City, State, Zip: Provide the address, city, state, and zip code for the facility owner(s).
SSN or Tax ID #: Provide the SSN or tax identification number for the land owner(s).
Telephone #, Contact Person, Fax #, and E-mail Address: Provide the telephone number, fax number, and e-mail address, and print the contact name.
Address Where Legal Notice May Be Served: Provide the name and address of the person authorized to accept service for each owner of the facility.
 
Part 8. OPERATOR INFORMATION:
Type of Business: Specify if the operator filing this Application is a sole proprietorship, partnership, corporation, or public agency.
Facility Operator: The person (e.g., individual(s), partnership, corporation, or public agency) to whom the approval to operate the facility is granted, and who is responsible for the overall operation of the facility including but not limited to, complying with regulatory requirements, complying with all applicable federal, state, and local requirements, and the design, construction, and physical operation of the operating area, and control the activities at a facility.
Address, City, State, Zip: Provide the address, city, state, and zip code for the facility operator.
SSN or Tax ID #: Provide the SSN or tax identification number for the operator.
Telephone #, Contact Person, Fax #, and E-mail Address: Provide the telephone number, fax number, and e-mail address, and print the contact name.
Address Where Legal Notice May Be Served: Provide the name and address of the person authorized to accept service for the operator of the facility.
 
Part 9. SIGNATURE BLOCK:
Signature (landowner or agent): A person(s) authorized to sign on behalf of the owner.
Signature (lessee): A person(s) authorized to sign on behalf of the person leasing the land, if applicable.
Signature (facility operator): A person(s) authorized to sign on behalf of the operator.
 
Part 10. OTHER:
Attach additional sheets to explain any responses that need clarification.

Credits

History
1. Editorial correction adding inadvertently omitted Appendix 2 (Register 97, No. 50).
2. Repealer and new appendix (form CIWMB E-1-77) filed 12-13-2004; operative 1-1-2005 pursuant to Government Code section 11343.4(c) (Register 2004, No. 51).
3. Amendment filed 11-10-2015; operative 1-1-2016 (Register 2015, No. 46).
This database is current through 4/5/24 Register 2024, No. 14.
Cal. Admin. Code tit. 27, Div. 2 Subd. 1 App. 1, 27 CA ADC Div. 2 Subd. 1 App. 1
End of Document