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r IV ENVIRONME AL IMPACT REPORT(EIR) <br /> HAS AN EIR BEEN PREPARED FOR THIS PROJECT? YES X❑NO <br /> IF"YES", PLEASE ENCLOSE A COPY ®YES ®NO <br /> IF"NO",WILL AN EIR BE PREPARED? DYES 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 EDPARTNERSHIP CORPORATION ❑GOVERNMENT AGENCY <br /> V.OPERATOR OWNER OF LAND ADDRE �O N L�,,yw � �@,� 6W TELEPHONE#: SSN OR TAX ID# <br /> 090 <br /> INFORMATION (Na/mel: ,� �,� s'.,,X.F- /tlC SG��Sa�«��C �Z 8$ab!? <br /> For land disposal, /01� AkA5ne J /A,�.tS E6,7 ~O 7 <br /> if operator is FACILITY OPERATOR ADDRESS: / TELEPHONE#: SSN OR TAX ID#: <br /> different from me): �—�q�` <br /> land owner,attach alie)� LWC <br /> lease or franchise ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br /> agreement. <br /> here y acknowledge tat I have read this application and the Report of Facility Information,if applicable,JTD or ROM and certify 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 /> T R (FAG[ TY OP TOR OR AGENT): <br /> SIGN ND O ER AGENT): <br /> TYPED NAME: TYPED NAME: <br /> TITLE: DATE: Lls,TITLE: - DATE: /g Q/ <br /> I.LIST OF ATTACHMENTS(CHECK IF APPLICABLE): <br /> REPORT OF FACILITY INFORMATION FlOPERATING LIABILITY FINANCIAL MECHANISM <br /> REPORT OF WASTE DISCHARGE ❑PRELIMINARY CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br /> ®JTD(RDSI/ROWD) FIFINAL CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br /> CONTRACT AGREEMENTS FINANCIAL RESPONSIBILITY DOCUMENTATION <br /> F-1 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 APPLICANT'S COMPLIANCE WITH CEQA REQUIREMENTS REGARDING <br /> THE PROPOSED PROJECT. <br /> EVIDENCE THAT THERE HAS BEEN COMPLIANCE WITH CEQA PRC,DIVISION 13,2100 et.sec <br /> version 4-6/96 <br />