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')tie Health Services of San Joaquin County r �? <br /> Fnvironmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> I. Does the business handle Hazardous Material//? { Yes /[ No [ ] <br /> b", <br /> a. <br /> b. Amount: <br /> 2 Does the business generate Hazardous Waste? Yes ['1 No [j <br /> a. Type: L✓rr�& r/ L In s ✓{r "�. <br /> b, Amount generated per month: `/0 n.i(r <br /> C. EPA : A..J't.:.!•,.0 CU;'�!' CO!! <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 #: r <br /> b. CRWQCB Discharge Requirement # i�'!, �.s •a iv'��i �* A r-< --<1102- <br /> C. <br /> -<11 2- <br /> C. County Permit#-1 n <br /> d. Other. <br /> 4. Type of sewage disposal system <br /> Ca. Private Scp6c System <br /> PI•IS/EIID Sanitation Permit #: <br /> b. Public Scwcr <br /> Name of System: <br /> City Discharge Permit#: <br /> S. of Water Supply <br /> a Name of Putic 11,0 SysL= <br /> b, Private Well <br /> PHSIEHD 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 22 035 (Rev 4/90) •. <br />