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Public Health Services of San Joaquin County <br /> Environmental Health Division <br /> BUSINESS UCENSE SURVEY <br /> 1. Docs the business handle hazardous Material? ,_ - Yes [ No [] <br /> b. Amount: <br /> Z Docs the business generate Hazardous Waste? / Yes [ j No [ j <br /> a. Type: <br /> b. Amount generated per month: <br /> C. EPAow-- <br /> 0 <br /> d. Storage method and time stored on premise: <br /> e. Waste disposal method: <br /> 3. Is the business presently under any Permits? Yes [ ) No ( ) <br /> a. State Permit #- <br /> b. CRW= Discharge Requirement # <br /> C. County Permit# �— <br /> d. Other. <br /> 4. Type of sewage dis *tt m <br /> A. rivate Sc tic System <br /> PHS/E D Sanitation Permit #: <br /> b. Pub11e Sewef <br /> Name of System: <br /> Clty Discharge Permit# <br /> 5. Type of Water Supply <br /> A. Name aPutkI4j9 System <br /> b. Private Wcll j <br /> PIIS/EHD Well--Permit #: <br /> Number of Employees: / <br /> Distance from septic system(s): w^ <br /> Distance from septic system(s): l <br /> Distance from Underground Storage Tank.- <br /> Distance <br /> ank:Distance from Hazardous Material Storage: <br /> Distancefrom Hazardous Waste Storage: <br /> rN 22 ms (Ow 4M) <br />