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FACILITY NAME Payless Food Mart Parking Lot <br />ID NUMBER CAH 111000595 <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION <br />F. CONTRACTOR INFORMATION (if applicable) <br />NAME MSE Environmental, Inc. <br />MAILING ADDRESS 880 West Verdulera Street <br />CITY Camarillo CA ZIP CODE 93010 - <br />G. CONTRACTOR CONTACT PERSON INFORMATION (if applicable) <br />CONTACT PERSON Oldemeyer Janice K. <br />(LAST NAME) (FIRST NAME) <br />PHONE NUMBER (805) 987-0217 <br />H. ACCEPTANCE OF COMMERCIAL WASTES <br />YES NO <br />Will your facility accept wastes from small quantity commercial source generators? <br />F-1 Lij <br />I. THE FOLLOWING LOCAL AUTHORITIES HAVE BEEN NOTIFIED OF THE <br />INTENDED OPERATION OF THE THHWCF: <br />❑X Environmental Management <br />X❑ Fire Department <br />X❑ Law Enforcement <br />❑ Traffic <br />❑X Air Quality <br />J. THE FOLLOWING LOCAL PERMITS HAVE BEEN OBTAINED FOR OPERATION <br />OF THE THHWCF: <br />No locals permits required. <br />Page of 4 <br />DTSC 8464 (9/92) <br />FS/ADMINFORMS\PBR FORM <br />