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% % <br /> Public Health Services of San Joaquin County <br /> Environmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> 1. Does the business handle IIazardous Material? Yes ( j No [ J <br /> a. Type: S vv. <br /> Am t: <br /> 2. oes t e bustn generate IR <br /> aelWaste? No <br /> a. Type: G/� G -v-� <br /> b. Amount generated per month: li('i <br /> C. EPA#: <br /> W Sj�a�Zll C/ <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. CRWQCB Discharge Requirement # <br /> C. County Permit <br /> d. Other. <br /> 4. Tof sewage disposal system <br /> a. Private Septic System <br /> PHS/F.HD 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 IIzO System: 4 <br /> Private Well <br /> PI-IS/EHD Well Permit #: <br /> Number of Employees: <br /> .�O T <br /> Distance from septic system(s): /-7" <br /> Distance from septic system(s): <br /> Distance from Underground Storage Tank N <br /> Distance from Hazardous Material Storage: <br /> Distance from Hazardous Waste Storage: /e2 D <br /> FH 22 035 (Rry 4/90) <br />