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TEMPORARY HOUSEHOLD HAZARDOUS WASTE <br /> COLLECTION FACILITY <br /> PERMIT BY RULE NOTIFICATION <br /> F. CONTRACTOR INFORMATION(if applicable) <br /> NAME Clean Earth Environmental Solutions, Inc. <br /> MAILING ADDRESS 933 First Avenue, Suite 200 <br /> CITY King of Prussia STATE PA ZIP 19406 <br /> G. CONTRACTOR CONTACT PERSON INFORMATION(if applicable) <br /> CONTACTPERSON Bettencourt Paul <br /> (LASTNANIE) (FIRST NAME) <br /> PHONE NUMBER (916)496-5039 <br /> H. ACCEPTANCE OF CESQG WASTES <br /> YES NO <br /> Q ❑ Will your facility accept wastes from conditionally exempt small quantity generators? <br /> I. THE FOLLOWING LOCAL AUTHORITIES HAVE BEEN NOTIFIED OF THE INTENDED <br /> OPERATION OF THE THHWCF: <br /> Q Environmental Management <br /> ❑✓ Fire Department <br /> ❑ Law Enforcement <br /> ❑✓ Traffic <br /> 0 Air Quality <br /> J. THE FOLLOWING LOCAL PERMITS HAVE BEEN OBTAINED FOR OPERATION OF THE '.. <br /> TIIHWCF: <br /> Encroachment Permit <br /> DTSC 8464(revised 10/07) PAGE 2 OF 4 <br />