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Public Health Services of San Joaquin County <br /> Environmental Health Division <br /> BUS'UWM UC ENSE SURVEY <br /> 1. Does the business handle Hazardous Material? Yes No [ ] <br /> 8. 'type: so <br /> b. Amount: <br /> 2 Does the business generate R atrdous Waste? Yes No [ ] <br /> ao Type: 6--9a S-le o ;// <br /> b. Amount generated per month: 4, �- <br /> c. EPAZe c7 i"i e e) <br /> d. Storage method and time stored on premise: <br /> e. Waste disposal method: l <br /> 3. Is the business presently under any Permits? Yes [ ] No ( ] <br /> a. State Permit #- <br /> b. C RWQCB Discharge Requirement #: <br /> C. County Permit# <br /> d. Other <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PHS/EHD Sanitation Permit # <br /> b. Public Sewer <br /> Name or System: L,. <br /> City Discharge Permit# <br /> S. Type of Water Supply <br /> a. Name of Putic 1110 System 7 C <br /> b. Private Wctt <br /> Pl iS/EHD Well Permit#: <br /> Number or Employees: <br /> Distance from septic system(s): <br /> Distance from septic system(s): <br /> Distance from Underground Storage Tank.- <br /> Distance <br /> ank:Distance from Hazardous Material Storage: <br /> Distance Irom Hazardous Waste Storage: <br />