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Ajtjwr � c -,k ? <br />blic Health Services of San Joaquin County <br />Environmental Health Division <br />t <br />1. Does the business handle Hazwkms ?vtato W? <br />Yes No ( j <br />a. Type: td- r <br />l v <br />b. • Amount; <br />2 Does the business generate EWzard0u& Waste? <br />Yes No [ j <br />a. TypC:t!a <br />b. Amount generated per month: <br />C. EPA#` <br />d. Storage method and time stored on premise: <br />e. Waste disposal method:�f° <br />3. Is the business presently under any Permits? <br />Yes No ( j <br />a. State Permit:: <br />b. M. WQCB Disd a ge Requirement <br />C. County Permit: <br />d. Other. /1-A A-0,19LA <br />4. Type of sewage disposal system <br />a. Private Septic System <br />PHSIUM Sanitation Permit <br />b. Public Scorer <br />Name of System: <br />City Discharge Permit <br />5. Type of Water Supply <br />b. Private Wed <br />PHSIEHD Weli Permit #: <br />Number of Employees: <br />Distance from septic Mwm(s� <br />• o <br />Distance from septic systems} <br />Distance from Underground Storage Tanickv UGST <br />I <br />Distance from rr. . •. •r <br />Distance from Hazardous WasteSLorage: <br />x <br />414 ZZ 025 0t4V 409M <br />