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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 H Hazardous Materia►? Yes No [ j <br /> a. T Type: <br /> b. Amount: Z (GJ <br /> 2. Does the business generate R=xxous Waste? Yes Lj No [] <br /> a. Type: G 1 <br /> b. Amount generated per month: <br /> C. EPA*- Gt-/G�I- U / —,/j <br /> d. Storage method and time stored on premise: <br /> e. Waste disposal method: AG V(Z�- �-- <br /> 3. Is the business presently under any Permits? Yes No [ j <br /> a. State Permit <br /> b. CRWQCB Dischar;e Requirement <br /> C. County Permit <br /> CL Other. 13�14 E,4 y a C 4 <br /> 4. T of sewage d'apcsal system <br /> Private Septic System <br /> PHSIEI•ID Sanitation Permit # <br /> b. Public Sewer <br /> Name of System: <br /> City Discharge Permit <br /> 5. Type of Water Supply <br /> a. Name of Pulic%0 System: <br /> Private Wed <br /> PHS/EHD Well Permit <br /> Number of Employees: Z <br /> Distance from septic systcm(s): <br /> Distance from septic system(s): <br /> Distance from Underground Storage Tank. V <br /> Distance from Hazardous Material Storage: <br /> Distance from Hazardous Waste Storage- <br /> EH <br /> torageEH 22 MS tNn V90) <br />