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Public Health Services of San Joaquin County <br />Eaviroamental Health Division <br />BUSINESS LICENSE SURVEY <br />1. Does the business handleeuazardous Material? Yes No ( ] <br />a. Type: f'�/ �4 i / <br />b. Amount <br />2 Does the business generate Hazardous Waste? Yes k No [ ] <br />a. Type: rtizgkEkZ or-A;9�/ <br />b. Amount generated per month: <br />C. EPA#: <br />d. Storage method and time stored on premise: <br />C. Waste disposal method <br />3. Is the business presently under any/Permits? Yes [ ] No ( ] <br />a. State Permit <br />b. CRWQCB Discharge RequirementL <br />C. County Permit # 7� a- fo Flie-lr— <br />d. Other. <br />4. Type of sewage disposal system <br />a. Private Septic System�f <br />. <br />PHS/EHD Sanitation Permit <br />Public Sewer <br />Name of System: <br />City Discharge Permit # <br />S. Type of Water Supply <br />(/a. J Name of Pulic H10 System: <br />b. Private Well <br />PHSIEHD Well Permit # <br />Number of Employees: <br />Distance from septic system(s): �[ <br />Distance from septic systems} /V f <br />Distance from Underground Storage TaNc 4/1 <br />14- <br />Distance from Hazardous Material Storage,. //��/ <br />Distance from Hazardous Waste Storage: /f///4 ---- <br />0422M (Mv ) <br />