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FROM _70IN MALL IONICO FII NO. : 9163549642 Jan. 14 2002 02:18PM P3 <br /> F 'YLS` PLCASE FNCt 01 L A" E)YES is ®NG <br /> IF'NO",WILL AN FiR BE PREPARED' Ljyr's NO <br /> WILL.A NL8A!.ivE DEOi.ARATION(ND)BE P?EPA9F:)? CYLS, IN 0 <br /> :F'YF,',PLEASE AN3WER 7 HE F{);LOWING: <br /> NOrl SCH n920920/2 WHO WILL PREPARE 7HF ND7 <br /> NOD SCH u93042C93 <br /> =APFROXI�A7,E DATE.OF COMFI <br /> TYPE OPERATING FACILITY: <br /> rl SOLE PROPRIETORSHIP PARTNERSHIP [:]CORPORATION []GOVERNMENT AGENCY <br /> V.OPERATOR ONNER OF LAND ADDRESS: TELLPI ION E 0: SSN OR TAX ID <br /> INFORMATION (Name):Michael P.C.Box 93,Tracy,CA 95378 209832 2355 680293953 <br /> For land disposal, RD <br /> If <br /> "D <br /> If operator is FAC I LI 71 Y NPREPT,0 R ADDRESS: TELFPHCNE 00! SSNOR TAX IC <br /> different from (Nzint.);Michael 209832 2355 680293953 <br /> land owner,attach Repeft P.C.Box 93,Tracy,CA 95118 <br /> -----E� EGNbTIO�07 ME <br /> lease cr franchise ADDR VLH R -LAL <br /> agradirsaipt. F.C.box 93,Tracy.CA 95376 <br /> 1�erebv ackricwla�ag--77­1 have read M71 -app Ti-calionand the Report of Fachfty irllorn2tlran,lfapp,lcable,JTL)or KQVVL1 and nertily that the <br /> information given is true and accurate t")the best of rny knowledge and belief. In oparat;ng the scilic,waste facility.I agree to comply with the <br /> conditions cf the permit and with iederai -,tate,and local enactment's. <br /> SIGN TU (.AND F-R- RA -N7): SIGNA7UR F I°y 0 OF RAG <br /> T?WEO NAME: TYPED NAME; <br /> Michael Repetto Michael RiI <br /> Owmar DATE: 1.11-02 TITLE; Owner DA TE: 1.11-02 <br /> VI.LIST OF ATTACHMeld (CHECK1F APPLICABLE): <br /> ®REPORT OF FACILITY INFORMATION ®OPERATING LIABILITY FINANCIAL MECHANISM <br /> [JREPORT OF WASTE DiSaHARGF OPRELIMINARY CLOgURE/I>OSTCLOSURE MAINTENANCE PLAN <br /> LjJTD(RDS11ROWD) ®FINAL CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br /> ®CONTRACT AGREEMENTS S [:]FINANCIAL RESPONSIBILITY DOCUMENTATION <br /> ®DEPARTMENT OF HEALTH SERVICES PERMIT [:]OTHER REGULATORY AGENCY PERMITS <br /> ®LOCAL USE;PLAN14 ING PERMITS ®OTHER <br /> ®CERTIFIED ENVIRONMENTAL REVIEW REPORTS I <br /> rl INFORMATION ON THE STATUS OF TME APPLICANT'S COMPLIANCE WITH CEQAREQU!REMENTS REGARI)tNG <br /> THE PROPOSED PROJECT. <br /> EVIDENCE THAT THERE HAS BEEN COMPLIANCE WITH CEQA PRC,DIVISION 13,2100 etsec <br /> version 4.6/96 <br />