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State of California -Environmental Protection A;ene) 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 />ClTY tockton <br />CA ZIP CODE 95206 <br />- -- ............ -........... <br />(LAST NAME <br />_..__---------_ ___ _____...................................................... _........... <br />FIRST NAME) <br />COUNTY San Joaquin <br />E. OPERATOR/AGENCY CONTACT PERSON INFORMATION <br />CONTACTPERSON Hudson <br />Alison <br />- -- ............ -........... <br />(LAST NAME <br />_..__---------_ ___ _____...................................................... _........... <br />FIRST NAME) <br />HONE NUMBER (209) 468-3066 <br />DTSC 8464 (9/92) Page of 4 <br />FS/ADMINFORMS\PBR FORM <br />