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f�;'� ti wig ? Public Health Services of San Joaquin County <br /> Environmental Health Division <br /> BUSLNESS LICI-NSE SURVEY <br /> 1. Does the business handle Fiazardow MaterW? Yes-6c, No ( ] <br /> a. Type: Q�G(�� <br /> b. Amount: SS <br /> 2 Does the business generate Haardom Waste? Yes No [] <br /> a. Type: ( ( 1 a S�—Z <br /> b. Amount generated per month: <br /> C. EPA#: <br /> d. Storage method and time stored on premise: <br /> e. Waste disposal method: , I i \ <br /> CA <br /> 3. Is the business presently under any Permits? Yes No ( ] <br /> a. State Permit #- <br /> b. CRWQCB Discharge Requirement #: <br /> C. County Permit <br /> d. Other: <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PHS/EIID Sanitation Permit # fi'=-,/) <br /> b. Public Seaver <br /> Name of System: <br /> City Discharge Perm' <br /> 5. Type of Water Supply <br /> a. Name of Pulic H2O System <br /> b. Private Wcd <br /> PHS/EHD Well Permit # <br /> Number of Employees V-3 <br /> Distance from septic system(s): <br /> Distance from septic system(s): <br /> Distance from Underground Storage Tanis rcQ ,� <br /> Distance from Hazardous Material Storage- <br /> Distance from Hazardous Waste Storage: <br /> EH n ms (tu.V%) <br /> 1l� <br /> /V <br />