California Integrated Waste Management Board

Local Enforcement Agency (LEA) Central

Forms

This page includes links to all of the forms found throughout LEA Central.

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Solid Waste Information System (SWIS) Facility/Site Data Entry Form

A form used by Board staff and LEAs to compile information on solid waste facilities, disposal sites, and operations. It is the vehicle for an LEA to obtain a site number (SWIS number assigned by Board staff) from the Board or for Board or LEA staff to submit updates to the Solid Waste Information System database.

Closed, Illegal and Abandoned (CIA) Disposal Sites Forms
Form Title and Description File Format
Closed, Illegal and Abandoned Site Prioritization--Defines CIA disposal site prioritization codes. Each CIA site must be identified by one of these codes.  
Declaration Form--A form to be used by CIWMB staff to provide information on their personal knowledge of the facts regarding a particular circumstance. The declaration is testified to under the laws of the State of California and provided to the CIWMB.
Gas Monitoring and Control System Plan Review (Draft)--A report template to be used when preparing a gas monitoring and control system plan.
Notice and Order Template--A template to be used when a notice and order must be issued against a disposal site. To be completed and acted upon by the CIWMB or local enforcement agencies.
Property Access Authorization Form--An authorization form used by CIWMB staff, their designated contractors and representatives to gain access to investigate CIA sites.

Property Access Authorization Cover Letter--A CIWMB letter used by staff, their designated contractors, and representatives, to request signature on an authorization form to gain access to investigate CIA sites.
Request for Hearing Form--A form to be completed by LEA staff, disposal site operators and/or owners or other interested parties to request a hearing before the CIWMB. The hearing can be requested for denial, suspension or revocation of a permit, administrative civil penalty, to challenge the terms and conditions of a permit, to appeal an enforcement order, to allege failure of the enforcement agency to act as required by law or regulation or to appeal the completeness review of a registration or standardized permit.
Sampling Log--Tracks where and when a soil sample is taken, the sample ID number and a physical description of the soil.
Site Assessment Form--A form used by CIWMB and LEA staff to assess CIA sites.
Site Identification Form--A form used to collect data on CIA facilities. Used by LEAs and the CIWMB.
Trench Log--A form for used to map trenches in field investigations conducted at CIA sites.
Closure Forms
Form Title and Description File Format
Closure Cost Estimate Worksheet (CIWMB Form 179-- Worksheet provides landfill stakeholders with guidance on the preparation and review of closure and postclosure maintenance cost estimates.

Closure Cost Estimate Worksheet Use Instructions
Final Closure Plan Completeness Review Checklist (CIWMB Form 174)--A checklist to determine if submitted final closure and postclosure maintenance plans meet Title 27, Article 2 technical requirements and if the plans are adequate to produce a detailed cost estimate for disbursement of financial assurance funds.
Final Closure Plan Qualitative Review Checklist (CIWMB Form 177)--Intended for use by regulatory agency staff to assist in the review of final closure and postclosure maintenance plans to determine if the plans may be considered technically adequate.
Solid Waste Facility Permit for Closed Sites

Recommended Procedures for Completion of Solid Waste Facility Permit for Closed Sites
Preliminary Closure Plan Completeness Review Checklist (CIWMB Form 176)--Intended for use by regulatory agency staff to assist in the review of preliminary closure and postclosure maintenance plans to determine if the plans may be considered complete.
Preliminary Closure Plan Qualitative Review Checklist (CIWMB Form 178)--Intended for use by regulatory agency staff to assist in the review of preliminary closure and postclosure maintenance plans to determine if the plans may be considered technically adequate.
Sample Request for Closure Cost Information--To be used as an example for facility operators of the type of information they should include in a closure cost estimate.
Enforcement Form
Form Title and Description File Format
Request for Hearing: LEAs give this form to solid waste facility operators when they propose or issue a permit.
Equipment Loan Form
Form Title and Description File Format
Equipment Loan Request Form (CIWMB Form 640)--Used by local enforcement agencies when requesting to borrow equipment from the Board for Board related field activities.
Inspection Report Forms

All of the inspection forms and directions for completion in this section were updated March 22, 2007 except as noted. The inspection forms are designed to be used with the Adobe Acrobat 8.0 Reader.

Send only single-sided inspection reports and any attachments.

Only inspection forms dated 1/07 or newer will be accepted.
Form Title and Description File Format
Inspection Form to Use for Activity Type--Used by LEAs and CIWMB staff to determine which inspection form to use when inspecting a particular type of facility or activity.
Asbestos-Containing Waste Disposal Site Inspection Report Addendum (CIWMB Form 52A) (Acceptable version date: 1/07)--This report is to be used in conjunction with the disposal site inspection report (CIWMB Form 52) to document the inspection of an asbestos disposal area at a disposal site.

Directions for Completion of Form 52A
Ash Transfer/Processing Operations and Ash Disposal/Monofill Facility Inspection Report (CIWMB Form 626) (Acceptable version date: 1/07)--This report is to be used to document the inspection of an ash transfer/processing operation or ash disposal/monofill facility.

Directions for Completion of Form 626
Closed Disposal Site Inspection Report (CIWMB Form 188) (Acceptable version date: 1/07)--This report is to be used to document the inspection of a CIA site.

Directions for Completion of Form 188
Compostable Materials Handling Operation and Facility Inspection Report (CIWMB Form 93) (Acceptable version date: 1/07)--This report is to be used to document the inspection of a compostable materials handling operation or facility.

Directions for Completion of Form 93
Construction and Demolition and Inert Debris (CDI) Transfer/Processing Facility Inspection Report (CIWMB Form 213) (Acceptable version date: 1/07)--This report is to be used to document the inspection of a CDI transfer/processing facility.

Directions for Completion of Form 213
Disposal Facility Inspection Report (CIWMB Form 52)
(Formerly Disposal Site Inspection Report) (Acceptable version date: 1/07)--This report is to be used to document the inspection of a disposal facility.

Directions for Completion of Form 52
Inert Debris Engineered Fill Operation Inspection Report (CIWMB Form 215) (Acceptable version date: 1/07)--This report is to be used to document the inspection of an inert debris engineered fill operation

Directions for Completion of Form 215
Inspection Report Addendum (CIWMB Form 3) (Acceptable version dates: any): This addendum is to be used to document additional information that does not fit on the primary inspection form used.
Inspection Report Order Form: This form can be used to order inspection forms over the internet.  
Nonhazardous Petroleum-Contaminated Soil Operation and Facility Inspection Report (CIWMB Form 76) (Acceptable version date: 1/07)--This report is to be used to document the inspection of a nonhazardous petroleum-contaminated soil operation or facility.

Directions for Completion of Form 76
Transfer Operation Inspection Report (CIWMB Form 73) (Acceptable version date: 1/07)--This report is to be used to document the inspection of a transfer operation.

Directions for Completion of Form 73
Transfer/Processing Facility Inspection Report (CIWMB Form 53) (Acceptable version date: 1/07)--This report is to be used to document the inspection of a transfer/processing facility.

Directions for Completion of Form 53

Permit Finding Request Forms
Form Title and Description File Format
Conformance Finding Request Form--Usually submitted to the CIWMB's Office of Local Assistance by Permitting and Inspection staff. Also used by LEAs to request an early consultation.
Financial Assurance Review Request Form--Usually submitted to the Board's Financial Assurance Unit by Permitting and Inspection staff. Also used by LEAs to request an early consultation.
Permitting Forms
Form Title and Description File Format
45-Day Owner/Operator Transfer Notice (CIWMB Form 675)--Form is used to identify a change of owner or operator of a solid waste facility. Completion of this form is not required by regulation, but it will provide the CIWMB and enforcement agency with the information required by PRC section 44005.
Enforcement Agency Notification (CIWMB Form 169)--This form will assist operators in meeting the requirements set for forth by Title 14 of the CCR, Section 18103.1: Any operator proposing to engage in solid waste handling pursuant to an EA notification shall notify the EA of its intent to operate in writing prior to commencing operations.
Five-Year Permit Review Form (CIWMB Form 678)--A form for use by LEAs in conducting solid waste facility permit five-year reviews.
Laundry List (Full Permit Application Checklist)--A checklist of application/permit submittal elements for solid waste facilities required to obtain a full permit from the CIWMB. Also known as the full permit Laundry List.  

Permit Reissuance Cover Page--This form is used to reissue a full solid waste facility permit when the 5-year permit review report concludes that there have not been any changes in design or operation since the permit was last issued (as directed by LEA Advisory No. 52).
Registration Permit (CIWMB Form 81)--A permit prepared by LEAs and submitted to the CIWMB to authorize operation of registration tier solid waste facilities.
Registration Permit Application (CIWMB Form 83)--An application form used by solid waste facility operators to apply for a registration permit.
Report of Facility Information (RFI) Amendment Checklist (CIWMB Form 216)--A form used by LEAs to document their review an RFI for completeness
Solid Waste Facility Permit, Full--A form to be completed by LEAs and submitted to the CIWMB for their concurrence in or objection to the issuance of the permit. This document specifies the operational parameters within which the facility issued the permit can operate.

Directions for Completion of Solid Waste Facility Permit

  

Solid Waste Facility Permit for Closed Sites--A form to be completed by LEAs and submitted to the CIWMB for their concurrence in or objection to the issuance of a permit that reflects the closure of the facility.

Recommended Procedures for Completion of Solid Waste Facility Permit for Closed Sites
Solid Waste Facility Permit Application (CIWMB Form E-1-77) --This form is completed by a solid waste facility operator and submitted to their EA to apply for a new solid waste facility permit, waste discharge permit, revision of a permit, exemption or waiver of a permit or permit review. It can also be used to submit documents to amend an application or to submit report of facility information amendments. A California Integrated Waste Management Board and Regional Water Quality Control Board form.

Directions for Completion of Form E-1-77 Updated
Standardized Composting Solid Waste Facility Permit (CIWMB Form 5000)--A form to be completed by LEAs and submitted to the CIWMB for their concurrence in or objection to the issuance of a permit for composting facilities.
Standardized Permit Application (CIWMB Form 92)--A form completed by certain California solid waste facility operators and submitted to LEAs prior to the beginning of operation of a facility or prior to making changes in operation of a facility.
Temporary Solid Waste Facilities Permit (CIWMB Form 91)--A form to be completed by an EA and, upon the CIWMBs concurrence, to be issued as a temporary solid waste facilities permit to a solid waste transfer or processing station or a composting facility for which a permit is required but has not been obtained. Solid waste facility operators only have Until May 9, 2008 to submit applications for these permits.
Three-Part Test Form
Form Title and Description File Format
Voluntary Residual Percentage Reporting (CIWMB Form 607)--A form used by CDI facility operators to voluntarily report the residual putrescible waste received at their facility.

CIA Disposal Sites Home | LEA Central

Last updated: May 6, 2008
LEA Support Services http://www.ciwmb.ca.gov/LEACentral/
Donnaye Palmer: donnayep@ciwmb.ca.gov (916) 341-6321