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State of California - Environmental Protection Agency Department of Toxic Substance Control <br />FOR OFFICIAL USE ONLY <br />DTSC REGIONAL OFFICE <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE MAY 2 3 2002 <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION ENVIROULENT HEALTH <br />PERMIT/SERVICES <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 />1. GENERAL INFORMATION <br />A. FACILITY ID NUMBER CAH 111000617 <br />B. FACILITY NAME Country Club Community Center - Karl Ross Post #16 Parking Lot <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />ADDRESS 020 Plymouth Road, Karl Ross Post #16 Parking Lot <br />CITY Stockton CA ZIP CODE 5230 <br />COUNTY San Joaquin <br />D. OPERATOR (PUBLIC AGENCY) <br />AGENCY NAME County of San Joaquin Department of Public Works <br />/ <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 DiCiano <br />................... --............................... ...... ....... .......................... _................. ........._............. __................. -- ._. <br />(LAST NAME) <br />Jennifer <br />... _........... .---- ............................... __._.... __._.-._.__.......... _.... ...... __...............__..... __............. <br />(FIRST NAME) <br />PHONE NUMBER 209) 468-3066 <br />DTSC 8464 (9/92) Page ❑ of 4 <br />FS/ADMINFORMSIPBR FORM <br />