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State of California - Environmental Protection Agency Department of Toxic Substance Control <br />FOR OFFICIAL USE ONLY 'NMENT A�. HEAL 11 <br />DTSC REGIONAL OFFICE r, r, r) <br />`r* , q V I C, F <br />TEMPORARY HOUSEHOLD HAZARDOUS wAsffi AUG 14 AM 8: 58 <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 />�FACILITY ID NUMBER AH 111000284 <br />[B. PACIELITY NAME Escalon Community Center <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />ADDRESS 1050 Escalon Avenue <br />CITY Escalon <br />CA ZIP CODE 5230 <br />COUNTY San Joaquin <br />COUNTY San Joaquin <br />.... . .. . .. . ....... <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 5201 <br />COUNTY San Joaquin <br />E. OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />CONTACT PERSON DiCiano Jennifer <br />(LAST NAME) (FIRST NAME) <br />PHONE NUMBER (209) 468-3066 <br />DTSC 8464 (9/92) Page 0 of 4 <br />FS/ADMINFORMS\PBR FORM <br />