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Public Health Services of San Joaquin County <br /> Environmental Health Division <br /> SUSIIiESS LICENSE SURVEY ��,//� <br /> 1. Does the business handle Ilarvdous Material? Yes Y4 No [ ] <br /> a. Type:( <br /> If,9 G �Z e e--, — <br /> b. Amount: <br /> 2 Does the business generate Hazardous Wave? ,c Y No [] <br /> a. Type- <br /> RI tti�pp - na1 V E <br /> b. Amount generated perEbaentl5.- n ,l <br /> #:� N�'I G f�/Dl? LG'(LLl ,4�•r.(� FI"A �itt✓ <br /> C. EPA <br /> L 7 a iJ U <br /> d. Storage method and time stored on premise: <br /> e. Waste disposal method: <br /> 3. Is the business presently under any Permits? <br /> Yes [ ] No [ ] <br /> a. State Permit #: <br /> b. CRWQCB Discharge Requirement #: o <br /> C. County Permit#: <br /> d. Other. <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PHS/EFID Sanitation Permit #: <br /> b. Public Sewer / <br /> Name of System: <br /> City Discharge Permit#: <br /> S. Type of Water Supply / <br /> a. Name of Putic II30 System: <br /> b. Private Well <br /> PHS/EHD Well Permit#: <br /> Number of Employees <br /> Distance from septic system(s): <br /> Distance from septic system(s): <br /> Distance from Underground Storage Tank: <br /> Distance from Hazardous Material Storage: <br /> Distance from Hazardous Waste Storage- <br /> EN Tl Das (M AM) <br />