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07-02-1998 05:08PM FPOM <br />State of California - Environmental Protection Agency <br />l FOR OFFICIAL USE ONLY <br />DISC REGIONAL OFFICE <br />MSE Enuironmental, Inc. TO 912094683078 P.08 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />Department of Toxic Substance Control <br />For use by agencies operating a Temporary Household Hazardous Waste Collection Facility ( HHWCF) under Perit y Rule. Each <br />location requires a separate form. <br />�X INITIAL NOTIFICATION REVISED NOTIFICATION Pta an <br />asterisk in the left margin next to the <br />revised information. <br />I. GENERAL INFORMATION <br />A. FACILITY ID NUMBER CAH 111000284 <br />B . FACILITY NAME Escalon Community Center <br />C . FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />ADDRESS I050 Escalon Avenue <br />CITY <br />COUNTY <br />Escalon <br />San Joaquin <br />D . OPERATOR (PUBLIC AGENCY) <br />CA ZIP CODE 95230 - <br />AGENCY NAME County of San Joaquin Department of Public Works <br />MAILING ADDRESS 1810 East Hazelton <br />CITY Stockton CA ZIP CODE 95201 <br />COUNTY San Joaquin <br />E . OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />CONTACT PERSON Hudson Alison <br />(LAST NAME) (FIRST NAME) <br />PHONE NUMBER (209) 468-3066 <br />DTSC 8464 (9192) Pae 1 of 4 <br />F&ADMINFORMSTBR FORM g <br />