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IV' MTAL IMPACT REPORT (I'R) <br />+ YES NO <br />HAS AN EIRtBEEN PREPARED FOR THIS PRO <br />IF *YES*, PLEASE ENCLOSE A COPY ®YES ®NO <br />IF 'NO', WILL AN EIR BE PREPARED? ®YES ONO <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 ❑PARTNERSHIP CORPORATION ®GOVERNMENT AGENCY <br />V. OPERATOR OWNER OF LAND ADDRESS: 9 9 9 9 S : Austin Road TELEPHONE i+: SSN OR TAX I <br />INFORMATION (N—):209 <br />Name):Klan t e c a 'CA 95336 2 0 9 941544481 <br />982-4298 <br />For land disposal, F r W r <br />if operator Is FACILITY OPERATOR ADDRESS: TELEPHONE M: SSN OR TAX I <br />different hose (N—): <br />land owner, attach Forward I SAME Same <br />lease or franchise ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br />agreement: 9999S, <br />I hereby acknowledge that I have read this application and the Report of Facility Information, if applicable, JTD or ROWD 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 />_____ . __ .. . .......... ..r ...�..�,. SIGNATURE (FACIL= OX6itATOR OR AGENT): <br />DATE: <br />General Manager <br />—J— <br />VI. LIST OF ATTAC (CHECK IF APPLICABLLQ: <br />OREPORT OF FACILITY INFORMATION [-]OPERATING uABiLrry FINANCIAL MECHANISM <br />®REPORT OF WASTE DISCHARGE ®PRELIMINARY CLOSURE/POSTCLOSURE MAINTENANCE PIAN <br />®LTD (RDSI/ROWD) ®FINAL CLOSURE/POSTCIASURE MAINTENANCE PLAN <br />®CONTRACT AGREF.M 1NTS ❑FINANCIAL. RESPONSIBILITY DOCUMENTATION <br />®DEPARTMENT OF HEALTH SERVICES PERMIT ®OTHER REGULATORY AGENCY PERMITS <br />®LOCAL USE/PLANNING PERMITS ❑OTHER <br />CERTIFIED ENVIRONMENTAL REVIEW REPORTS (CEQA) <br />DINFORMATION ON THE STATUS OF THE APPLICANTS COMPLIANCE WITH CEQA REQUIREMENTS REGARDING <br />THE PROPOSED PROJECT. <br />1:1 EVIDENCE THAT THERE HAS BEEN COMPLIANCE WITH CEGA PRC, DIVISION 13, 2100 st.sec <br />version 4 - 6/96 <br />