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APPROXIMATE DATE OF COMPLE TYPE OF BUSINESS OPERATING FACILITY: ®SOLE PROPRIETORSHIP ®PARTNERSHIP ®CORPORATION GOVERNMENT AGENCY V. OPERATOR OWNER OF LAND ADDRESS: TELEPHONE #: SSN OR TAX ID # INFORMATION (Name): San 1810 East Hazelton Ave. (2009 468 For land disposal, Joaquin CountyStockton, CA 95205 306 if operator in FACILITY OPERATOR ADDRESS: TELEPHONE #: SSN OR TAX ID #: different from (Name6an 1810 East Hazelton Ave. 209)468- land owner,attach Stockton, CA 95205 3066 lease or franshse ADDRE S WHERE LEGAL OTICE MAY BE SERVED: agreement. 1810 E. Hazelton Ave. Stockton, CA 95205 1 hereby acknowledge that 1 have read this application and the Report of Facility Information, if applicable, JTD or ROWD and certify that the 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 conditions of the permit and with federal, state, and local enactment's. SIGNATURE (LANDOWNER ORjAGENT): SIGNATOR Y OPER,ITOR OR AGENT): Tom Horton Tom Horton TITLE: DATE: TITLE:DATE: Integrated Waste Manager 11/30/98 Inte fated Waste Manager 11/30/98 VI. LIST OF ATTACHMENTS (CHECK IF APPLICABLE): ®REPORT OF FACILITY INFORMATION ®OPERATING LIABILITY FINANCIAL MECHANISM ®REPORT OF WASTE DISCHARGE ®PRELIMINARY CLOSURE/POSTCLOSURE MAINTENANCE PLAN ®JTD (RDSI/ROWD) ®FINAL CLOSURE/POSTCLOSURE MAINTENANCE PLAN ®CONTRACT AGREEMENTS ®FINANCIAL RESPONSIBILITY DOCUMENTATION ®DEPARTMENT OF HEALTH SERVICES PERMIT ®OTHER REGULATORY AGENCY PERMITS ®LOCAL USE/PLANNING PERMITS 13OTHERPreyiously submitted Report of Station ❑CERTIFIED ENVIRONMENTAL REVIEW REPORTS (CEQA) Information is still valid. ®INFORMATION ON THE STATUS OF THE APPLICANT'S COMPLIANCE WITH CEQA REQUIREMENTS REGARDING THE PROPOSED PROJECT. ®EVIDENCE THAT THERE HAS BEEN COMPLIANCE WITH CEQA PRC, DIVISION 13, 2100 et.sec version 4 - 6/96