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s ' <br />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 <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 <br />ss Food Mart Parking Lot <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />ADDRESS 18980 North Highway 88 <br />ITY ockeford <br />CA ZIP CODE <br />95236 <br />COUNTY San Joaquin <br />San Joaquin <br />D. OPERATOR (PUBLIC AGENCY) <br />AGENCY NAME ounty of San Joaquin Department of Public Works <br />AILING ADDRESS P.O. Box 1810, 1810 East Hazelton <br />ITY <br />tockton <br />CA ZIP CODE 95201 <br />COUNTY <br />San Joaquin <br />E. OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />ONTACT PERSON DiCiano Jennifer <br />—-...__...._.. —_..----.............. __... ...... _..... - ..... _............. -.... __.-_....._._... ...... ---......... __..... ....... ... _........... <br />_..-_--..__._..__..__.._—_.._...._ <br />(LAST NAME) FIRST NAME) <br />HONE NUMBER 209) 468-3066 <br />DTSC 8464 (9/92) Page ❑ of 4 <br />FS/ADMINFORMSU'BR FORM <br />