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me Health Services of San Joaquin County <br /> Environmental Health Division _yTL <br /> BUSWESS ISCENSESURVLY PSid <br /> 1. Does the business handle hazardous Material? Free"i, p <br /> r9 (05e, Ye44 No ( j <br /> � / <br /> a. Type: A7- <br /> b. Amount: <br /> 2 Does the business generate I-Iamrdous Waste? yes-Iiy No [ ] <br /> a TYPe 1 c� L �L7 / �` \kloy�—Wds �lW <br /> b. Amount generated per month: <br /> \ <br /> C. EPA#: <br /> d. Storage method and time stored on premise: `: <br /> C. Waste disposal method: <br /> J <br /> 3. Is the business presently under any Permits? Yes g]/ No (] <br /> a. State Permit #: <br /> b. CRWOCB Discharge Requirement # <br /> C. County Permit#: Flt= 47/'m; " /tU 3 A476,2,4,: H*"f/' OEs <br /> d. Other. <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PIIS/EHD Sanitation Permit #: <br /> b. Public <br /> Name of Syst System: Y�l <br /> City Discharge Permit# <br /> 5. Type of Water Supply <br /> a. Name of Pulic H2O System: <br /> b. Private Well , 1 <br /> PHSIEHD Well Permit #: <br /> Number of Employees: <br /> Distance from septic systcm(s): <br /> Distance from septic system(s): <br /> Distance from Underground Storage Tanla <br /> Distance from Hazardous Material Storage: <br /> Distance from Hazardous Waste Storage: <br /> EH]3 MS rPcv AM) •• <br />