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IV n ENVIRONMIW IMPACT REPORT(EIR) <br /> HAS AN EIR BEEN PREPARED FOR THIS PROJECT? [K]YES NO <br /> IF-YES", PLEASE ENCLOSE A COPY :]YES(cover) F_jNO <br /> IF-NO",WILL AN EIR BE PREPARED? YES [:]NO <br /> WILL A NEGATIVE DECLARATION(ND)BE PREPARED? YES ®NO <br /> IF"YES-,PLEASE ANSWER THE FOLLOWING: <br /> WHO WILL PREPARE THE ND? <br /> APPROXIMATE DATE OF COMPLETION: <br /> TYPE OF BUSINESS OPERATING FACILITY: <br /> ❑SOLE PROPRIETORSHIP MPARTNERSHIP CORPORATION ®GOVERNMENT AGENCY <br /> V.OPERATOR OWNER OF LAND ADDRESS: TELEPHONE#: SSN OR TAX ID# <br /> INFORMATION (Name): 1810 East Hazelton Avenue (209)468-3066 <br /> For land disposal, San Joaquin County Stockton,California 95201 <br /> if operator is FACILITY OPERATOR ADDRESS: TELEPHONE#: SSN OR TAX ID#: <br /> different from (Name): 1810 East Hazelton Avenue (209)468-3066 <br /> land owner,attach San Joaquin County Stockton,California 95201 <br /> lease or franchise ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br /> agreement. 1810 East Hazelton Avenue Stockton,California 95201 <br /> 1 hereby acknowledge that I have read this application and the Report of Facility Information, if applicable,JTD or ROWD and certify that the <br /> information given is true and accurate to the best of my knowledge and belief. In operating the solid waste facility, I agree to comply with the <br /> conditions of the permit and with federal,state,and local enactment's. <br /> SIGNATURE(LAND OWNER OR AGENT): SIGNATURE(FACILITY OPERATOR OR AGENT): <br /> zoOperator same as owner <br /> TYPED NAME: TYPED NAME: <br /> W.Michael Carroll 69— <br /> TITLE: <br /> ZTITLE: ::� DATE: TITLE: DATE: <br /> Senior Engineer,Solid Waste Division,Department of Public Works <br /> VI.LIST OF ATTACHMENTS(CHECK IF APPLICABLE): <br /> REPORT OF FACILITY INFORMATION OPERATING LIABILITY FINANCIAL MECHANISM <br /> REPORT OF WASTE DISCHARGE ❑PRELIMINARY CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br /> ❑JTD(RDSI/ROWD) FINAL CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br /> MCONTRACT AGREEMENTS FINANCIAL RESPONSIBILITY DOCUMENTATION <br /> DEPARTMENT OF HEALTH SERVICES PERMIT ❑OTHER REGULATORY AGENCY PERMITS <br /> ❑LOCAL USE/PLANNING PERMITSXIOTHER:Revision to RSI(submitted earlier) <br /> CERTIFIED ENVIRONMENTAL REVIEW REPORTS(CEQA) <br /> F-IiNFORMATION ON THE STATUS OF THE APPLICANT'S COMPLIANCE WITH CEQA REQUIREMENTS REGARDING <br /> THE PROPOSED PROJECT. <br /> EVIDENCE THAT THERE HAS BEEN COMPLIANCE WITH CEQA PRC,DIVISION 13,2100 et.sec <br /> version 4-6/96 <br />