Laserfiche WebLink
0 <br /> Part 8.OPERATOR INFORMATION(For disposal site,if operator is different from land owner,attach lease or other agreement) <br /> TYPE OF BUSINESS: <br /> ®SOLE PROPRIETORSHIP PARTNERSHIP ®CORPORATION ❑GOVERNMENT AGENCY <br /> FACILITY OPERATOR(S) SSN OR TAX ID#: <br /> (Name): <br /> ADDRESS,CITY,STATE,ZIP TELEPHONE#: <br /> FAX#: <br /> E-MAIL ADDRESS: <br /> CONTACT PERSON(Print Name): <br /> ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br /> Part 9.SIGNATURE BLOCK <br /> Owner: <br /> tk+ `under penalty bf.pel7ury#hal the Informatron I provided fqr this appUcatlon Arid for any atf2hmerits.is true and acqurpte`tA ttie best of trty kriowled a and,t�ellef. 1. <br /> art) are that the operator antentlsb gperate a soiidwaste faellfy at the site s�i3ted above pilrUfinfto this' pp)ication and if fr"cferstarict that 1 May,` e r s disible for the <br /> I erator ail to eet a ticable re„ulrements <br /> P, t p <br /> SIGNATURE(LAND OWNER OR AGENT): <br /> PRINTED NAME: <br /> TITLE: DATE: <br /> Operator: <br /> 1 #+under penalty cif°per)ury th t the information curitalned�n this applldgtIon and ati attachments i true"arid eccurnte to#heybest of myknowTedge and b ile.; <br /> SIGNATURE(FACILITY OPERATOR OR AGENT): <br /> PRINTED <br /> 'NAME: <br /> 1 D...� 1 <br /> TITLE: DATE: <br /> Part 10. OTHER (Attach additional sheets to explain any responses that need clarification). <br /> Page 4 <br />