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Public Health Services of San Joaquin County <br /> Environmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> 1. Does the business handle Hazardous Material? Yes / No [ ] <br /> a. Type: A6G 4,, )&- <br /> qv: GOz 1O�r� . e,.,7y c'+tet CU�'lc�i bifj <br /> b. Amount�0O�����!o����YI�+L <br /> ��der r d✓✓W�'""<'_S1L` �l-iu� _ �2'+ ��f o���'9 <br /> 2. Does the business generate Hazardous Wave? Yes [] No <br /> a. Type: <br /> b. Amount generated per month: <br /> C. EPA#: <br /> d. Storage method and time stored on premise: <br /> e. Waste disposal method: <br /> 3. Is the business presently under any Permits? Yes [.j' No [] <br /> a. State Permit #: <br /> b. CRWQCB Discharge Requirement #: <br /> C. County Permit#: Z'�' at/77�j fcr,✓l _ firou�G�%��."luT/,nq �-(V�/cl,'�.< �L,•�u/y <br /> 9c 1868 yq <br /> d. Other: <br /> 4. Type of sewage disposal system <br /> Com' Private Septic System p ` x/19 <br /> PHS/EHD Sanitation Permit * - ��J� 79v o(9✓e' AS ,:ill �'L <br /> b. Public Sewer <br /> Name of System: <br /> City Discharge Permit#: <br /> 5. Type of Water Supply <br /> a. Name of Pulic 1110 System i <br /> b. Private Well <br /> PHS/EHD Well Permit #: <br /> Number of Employees: �O <br /> Distance from septic system(s): <br /> Distance from septic system(s): <br /> Distance from Underground Storage Tank <br /> Distance from Hazardous Material Storage: .41A <br /> Distance from Hazardous Waste Storage: <br /> E1122 O.i5 (11ev 4/90) <br />