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IF"YES", PLEASE ENCLOSE A CO ®YES ®NO <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 ®PARTNERSHIP CORPORATION ®GOVERNMENT AGENCY <br /> V.OPERATOR OWNER OF LAND ADDRESS: TELEPHONE#: SSN OR TAX ID# <br /> s <br /> INFORMATION (Name): <br /> For land disposal, <br /> If operator is FACILITY OPERATOR ADDRESS: TELEPHONE#: SSN OR TAX ID#: <br /> different from (Name): <br /> land owner,attach <br /> lease or franchise ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br /> agreement <br /> hereby acknowledge tat Mave read this application and he Report of Facility Information,if applicable,J I U or RMD and cerfify 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 /> TYPED NAME: TYPED NAME: <br /> TITLE: DATE: TITLE: DATE: <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 /> ®CONTRACT AGREEMENTS ®FINANCIAL RESPONSIBILITY DOCUMENTATION <br /> ®DEPARTMENT OF HEALTH SERVICES PERMIT ®OTHER REGULATORY AGENCY PERMITS <br /> ®LOCAL USE/PLANNING PERMITS ®OTHER <br /> ®CERTIFIED ENVIRONMENTAL REVIEW REPORTS(CEQA) <br /> ®INFORMATION ON THE STATUS OF THE APPLICANTS COMPLIANCE WITH CEQA REQUIREMENTS REGARDING <br /> THE PROPOSED PROJECT. <br /> ®EVIDENCE THAT THERE HAS BEEN COMPLIANCE WITH CEQA PRC,DIVISION 13,2100 etsec <br /> version 4-6/96 <br /> 9 4 f <br />