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State of California— California Environmental Protection Agency Department of Toxic Substances Control <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE ���� <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION DEC 2 9 2014 <br />For use by public agencies operating a Temporary Household Hazardous Waste Collection Facility (THHWCF) under Permit By Rule. Each location requires a <br />separate form. ENVIRONMENTAL HEALTH <br />PERMITISi RVICES <br />EIINITIAL NOTIFICATION <br />I. GENERAL INFORMATION <br />A. FACILITY ID NUMBER <br />B. FACILITY NAME <br />❑ REVISED NOTIFICATION Put an asterisk in the left margin next to the revised <br />information <br />CAH 111000284 <br />Escalon Community Center <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY LOCATION <br />ADDRESS 1055 Escalon Avenue <br />CITY Escalon STATE CA ZIP 95320 <br />COUNTY San Joaquin <br />D. OPERATOR (PUBLIC AGENCY) <br />AGENCY NAME San Joaquin County <br />Department of Public Works <br />MAILING ADDRESS P.O. Box 1810, 1810 E. Hazelton Avenue <br />CITY Stockton STATE CA ZIP 95201 <br />COUNTY San Joaquin <br />E. OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />CONTACT PERSON Moberly Elisa <br />(LAST NAME) (FIRST NAME) <br />PHONE NUMBER 209.468.3066 <br />DTSC 8464 (revised 10/07) PAGE 1 OF 4 <br />