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State of California - Environmental Protection Agenc <br />FOR OFFICIAL USE ONLY <br />DTSC REGIONAL OFFICE <br />r� <br />TP <br />Department of T�, q Substance Control <br />1 <br />�G1 <br />"i <br />r� <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE N <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 />❑ 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 CAH111000894 <br />B. FACILITY NAME Payless Food Mart Parking Lot <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />ADDRESS 18980 N. Hiehwav 88 <br />CITY <br />Lockeford <br />COUNTY San Joaquin <br />CA ZIP CODE 95236 - <br />D. OPERATOR (PUBLIC AGENCY) <br />AGENCY NAME Countv of San Joauuin DeDartment of Public Works <br />MAILING ADDRESS <br />CITY <br />COUNTY <br />P.O. Box 1810, 1810 East Hazelton <br />Stockton CA ZIP CODE 95201 - <br />San Joaquin <br />E. OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />CONTACT PERSON Hudson <br />(LAST NAME) <br />PHONE NUMBER (209) 468-3066 <br />DTSC 8464 (9/92) <br />FS/ADMINFORMSIPBR FORM <br />Alison <br />(FIRST NAME) <br />Page of 4 <br />