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[APPROXIMATE DATE <br />TY , - BUSINESS OPERATING FACILITY: <br />SOLE PROPRIETORSHIP ®PARTNERSHIP ®CORPORATION <br />V. OPERATOR OWNER OF LAND ADDRESS <br />INFORMATION (Name): San 1810 East Hazelton Ave. <br />For land disposal. Joaquin County Stockton, CA 95205 <br />if operator is FACILITY OPERATOR ADDRESS: <br />different from (Nams6an 1810 East Hazelton Ave. <br />land owner, attachStockton, CA 95205 <br />lease or franchise ADDREil; WHERE LEGAL NOTIC£ MAY R£ S£RV£n, <br />. Hazelton Ave. Stockton, CA 95205 <br />IN: <br />GOVERNMENT AGENCY <br />TEL22EMONE s BSN OR 10 1 <br />01468 <br />TELEPHONE *. ISBNORTAX 10 a: <br />;209)468— <br />_• --...,..y.......,.......® .uvea una Opp -14 MIM UM rwpurc oe raun" mn7rn4uerr. R appaCaoee. Jlu or KVWU and cart" that the <br />information given is true and accurate to the best of my knowledge and belief. In operating the sow waste facility. I agree to comply with the <br />conditions of the permit and with federal, state, and local enactment's. <br />SIGNATURE' NIS-GwNE7OvR AGENT): SIGNATURE EACILE OPERATOgOR AGENT►: <br />' -z- �/ <br />-TYPED NAME: TYPED NAME: IF <br />Tom Horton I Tom Horton <br />Inte rated Waste Mann' er 11/30/98 VA�G <br />b_ � Interfated Waste Maaaszer 11/30/98 <br />VL UST OF ATTACHMENTS (CHECK IF <br />®REPORT OF FACILITY INFORMATION ®OPERATWG UASIIUTY FINANCIAL MECHANISM <br />❑REPORT OF WASTE DISCHARGE ®PRELIMINARY CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br />®JTD (RDSUROWD) ®FINAL CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br />®CONTRACT AGREEMENTS ®FINANCIAL RESPONSIBILITY DOCUMENTATION <br />®DEPARTMENT OF HEALTH SERVICES PERMIT ®OTHER REGULATORY AGENCY PERMITS <br />[]LOCALUSEIPLANNING PERMITS orAERPreviously subm? tted Report Of Station <br />®CERTIFIED ENVIRONMENTAL REVIEW REPORTS (CEOAI Information is Still valid. <br />®INFORMATION ON THE STATUS OF THE APPLICANT'S COMPLIANCE WITH CEOA RiiauiREMENT3 REGARDING <br />THE PROPOSED PROJECT. <br />MEVIOENCE THAT THERE HAS BEEN COMPLIANCE WITH CEOA PRC. DIVISION 13. 2100 et.sae <br />version 4 • 8/98 <br />