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Part 5.COMPLIANCE WITH CALIFORNIA ENVIRONMENTAL QUALITY ACT(CEQA)(Check applicable boxes) <br /> A. CHECK BOX(ES)IF ENVIRONMENTAL DOCUMENT WAS OR WILL BE PREPARED FOR THIS PROJECT AND PROVIDE THE STATE CLEARINGHOUSE NUMBER(SCH#): <br /> ENVIRONMENTAL IMPACT REPORT(EIR)SCH# <br /> NEGATIVE DECLARATION(ND)/MITIGATED NEGATIVE DECLARATION(MND)SCH# <br /> F-JADDENDUM TO(Identify environmental document) SCH# <br /> B. IF ENVIRONMENTAL DOCUMENT($)WAS NOT PREPARED,PLEASE PROVIDE THE FOLLOWING INFORMATION: <br /> r--jCATEGORICAUSTATUTORY EXEMPTION(CE/SE) <br /> EXEMPTION TYPE GUIDELINE# <br /> Part G.LIST OF ATTACHMENTS(Fill in the date for each document checked) <br /> A.REQUIRED WITH ALL APPLICATION SUBMITTALS: <br /> F-JRFI/JTD El ENVIRONMENTAL DOCUMENT(S): <br /> F-JLOCAL USE/PLANNING PERMITS ❑EIR <br /> LOCATION MAP ❑MND/ND <br /> MITIGATION MONITORING IMPLEMENTATION SCHEDULE ❑EXEMPTION <br /> 0 ADDENDUM <br /> B. ADDITIONAL REQUIRED DOCUMENTS FOR LANDFILLS ONLY: I� <br /> OPERATING LIABILITY FINANCIAL MECHANISM `` []FINANCIAL RESPONSIBILITY DOCUMENTATION <br /> �CLOSURE/POST CLOSURE MAINTENANCE PLAN ❑LANDFILL CAPACITY SURVEY RESULTS(see instructions) <br /> • PRELIMINARY <br /> ❑ FINAL <br /> C. IF APPLICABLE: <br /> REPORT OF WASTE DISCHARGE DEPT,OF HEALTH SERVICES PERMIT <br /> ❑CONTRACT AGREEMENTS SWAT(Air and water) <br /> fSTORMWATER PERMIT APPLICATION MWETLANDS PERMITS <br /> E1NPDES PERMIT APPLICATION VERIFICATION OF FIRE DISTRICT COMPLIANCE <br /> OTHER <br /> Part 7.OWNER INFORMATION (For disposal site,if operator is different from land owner,attach lease or other agreement) <br /> TYPE OF BUSINESS: <br /> 1:1 SOLE PROPRIETORSHIP R PARTNERSHIP OCORPORATION MGOVERNMENTAGENCY <br /> OWNER(S)OF LAND SSN OR TAX ID# <br /> (Name): <br /> ADDRESS,CITY,STATE IP TELEPHONE#: <br /> X00 N <br /> an V 2vq-�� La <br /> FAX#: <br /> E-MAIL ADDRESS: <br /> Yafoe,1 mail JC �C m <br /> CONTACT PERSON(Print Name): <br /> �U- c D-1 -111 e <br /> Page 3 <br />