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State of California - Environmental Protection Agency Department of Toxic Substance Control <br />FOR OFFICIAL USE ONLY Y e <br />DTSC REGIONAL OFFICE 0 R <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 />ACILITY ID NUMBER AH111000595 <br />ACILITY NAME Pavless Food Mart Parking Lot <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />ADDRESS 18980 North Highway 88 <br />I Lockeford <br />CA ZIP CODE 95236 <br />COUNTY San Joaquin <br />D. OPERATOR (PUBLIC AGENCY) <br />AGENCY NAME ounty of San Joaquin Department of Public Works <br />ILING ADDRESS P.O. Box 1810, 1810 East Hazelton <br />ClTY Stockton CA ZIP CODE 95201 <br />COUNTY San Joaquin <br />E. OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />CONTACTPERSON Hudson Alison <br />_... --... _ _.___.._....-...—_... _......._..- .................. ... __....... _...._....... <br />---_._._...__....._ _ _ .. __..__._......_.—�.. <br />LAST NAME) FIRST NAME) <br />HONE NUMBER 209) 468-3066 <br />DTSC 8464 (9/92) Page o f 4 <br />FS/ADMINFORMS\PBR FORM <br />