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Irl 1`��G• Public Health Services of San Ioaquin County <br /> Environmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> 1. Does the business handle F us ? Yes No [] <br /> a. S , <br /> b. Amount: <br /> Z. Does the business generate Hazardous Waste? Yes [] No [] <br /> a. : 1,0 6? F <br /> b. Amount generated per month: <br /> c. EPA#: <br /> r <br /> d. Storage method and time stored on premise: c� <br /> e. Waste disposal method: <br /> 3. Is the business presently under any Permits? Yes [] No [] <br /> a. State Permit#- <br /> b. CRWQ Requirement #: N• u/ <br /> inS I.UGC5�C1 V, — f — <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 <br /> Name of System: <br /> City Discharge Permit#: <br /> 5. Type of Water Supply <br /> a. Nate of Pulic 1120 Systems -- <br /> b. Private Wen CC <br /> PHS/EHD Well Permit : J <br /> Number of Employees: <br /> Distance from septic system(s): 1 �! <br /> Distance from septic system(s): no <br /> Distance from Underground Storage Tank:, <br /> Distance from Hazardous Material Storage: <br /> Distance from Hazardous Waste Storage. <br /> M za ass (R"4M) <br /> .a <br />