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State of California - Environmental Protection Agency <br />FOR OFFICIAL USE ONLY <br />Department of Toxic Substance Control <br />DTSC REGIONAL OFFICE � E CC E � V [FD <br />TEMPORARY HOUSEHOLD HAZARDOUS WASTE MAY 2 3 2002 <br />COLLECTION FACILITY <br />PERMIT BY RULE NOTIFICATION ENVIR04MENT 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 />El INITIAL NOTIFICATION ® REVISED NOTIFICATION Put an <br />asterisk in the left margin next to the <br />revised information. <br />I. GENERAL INFORMATION <br />A. FACILITY ID NUMBER CAH 111000615 <br />B. FACILITY NAME Larch Clover Community Center Parking Lot <br />C. FACILITY ADDRESS OR LEGAL DESCRIPTION OF FACILITY <br />LOCATION <br />* ADDRESS 11157 West Larch Rd. <br />* CITY Tracy CA ZIP CODE 95376 - <br />COUNTY San Joaquin <br />D. OPERATOR (PUBLIC AGENCY) <br />AGENCY NAME County of San Joaquin Department of Public Works <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 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 />