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State of California - Environmental Protection Agency Department of Toxic Substance Control <br />FOR OFFICIAL USE ONLY - <br />DTSC REGIONAL OFFICE i <br />,.11..,;-131 P11 3: 07 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />For use by agencies operating a Temporary Household Hazardous Waste Collection Facility (THHWCF) under Permit By Rule. Each <br />location requires a separate form. <br />❑X INITIAL NOTIFICATION ❑ REVISED NOTIFICATION Put an <br />asterisk in the left margin next to the <br />revised information. <br />I. GENERAL INFORMATION <br />A. FACILITY ID NUMBER CAH111 <br />B . FACILITY NAME Payless Food Mart Parking Lot <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />ADDRESS 18980 North Hiehwav 88 <br />CITY <br />COUNTY <br />Lockeford <br />San Joaquin <br />D . OPERATOR (PUBLIC AGENCY) <br />CA ZIP CODE 95236 - <br />AGENCY NAME County of San Joaquin Department of Public Works <br />MAILING ADDRESS P.O. Box 1810, 1810 East Hazelton <br />CITY Stockton CA ZIP CODE 95201 - <br />COUNTY San Joaauin <br />E. OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />CONTACT PERSON Hudson Alison <br />PHONE NUMBER <br />DTSC 8464 (9/92) <br />FS/ADMINFORMS\PBR FORM <br />(LAST NAME) <br />(209)468-3066 <br />(FIRST NAME) <br />Page 1 of 4 <br />