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IV ENVIRONM . IMPACT REPORT(EIR) <br /> HAS AN EIR BEEN PREPARED FOR THIS PROJECT? ®YES ®NO <br /> IF"YES", PLEASE ENCLOSE A COPY ❑YES ®NO <br /> IF"NO",WILL AN EIR BE PREPARED? ❑YES ®NO <br /> WILL A NEGATIVE DECLARATION(ND)BE PREPARED? ElYES 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 ®CORPORATIONGOVERNMENT AGENCY <br /> V.OPERATOR OWNER OF LAND ADDRESS: TELEPHONE#: SSN OR TAX ID# <br /> INFORMATION (Name):San 6484 North Waverly Road (209) <br /> For land disposal, Joaquin County Linden, California 95236 887-3969 <br /> if operator is FACILITY OPERATOR ADDRESS: TELEPHONE#: SSN OR TAX ID#: <br /> different from (Name): San 6484 North Waverly Road (209) <br /> land owner,attach Joaquin Coun y Linden, California 95236 887-3969 <br /> lease or franchise ADDRESS WHERE LEGAL NOTICE MAY BE SERVED: <br /> agreement. <br /> I hereby acknowledge that 1 have read this application and the Report of Faciflty Information,if applicable,JTD or R WD and rtify 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 enactments. <br /> SIGNATURE D <br /> OYVNER OR AGENT): SIGNATURE(FACILITY OPERATR OR <br /> TYPED NAME: TYPED NAME: <br /> Tom Horton Tom Horton <br /> TITLE: DATE: TITLE: DATE: <br /> Integrated Waste Manager /41Integrated Waste Manager g ls" caC� <br /> Vi.LIST OF ATTACHMENTS(CHECK IF APPLICABLE): <br /> REPORT OF FACILITY INFORMATION ®OPERATING LIABILITY FINANCIAL MECHANISM <br /> ®REPORT OF WASTE DISCHARGE MPRELIMINARY CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br /> ®JTD(RDSI/ROWD) ❑FINAL CLOSURE/POSTCLOSURE MAINTENANCE PLAN <br /> ®CONTRACT AGREEMENTS ®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 /> INFORMATION ON THE STATUS OF THE APPLICANTS 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 />