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i <br /> • Public Health Services of San Joaquin Count <br /> Environmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> 1. Does the business handle Ilarardous Material? Yes No [ ] <br /> a. Type: .,.e <br /> b. Amount: <br /> 2. Does the business generate ILvatdous Waste? Yes [vf No [] <br /> LL� <br /> a. Type: (X)Qtik-t- Ol i U� lS�c �JN�1 LrY PzZ1� LUCh�C SntfFPr <br /> i <br /> b. Amount generated per month: r __ <br /> C. EPA#: <br /> d. Storage method and time stored on premise: S c' ru m <br /> C. Waste disposal method: i,"L-??J c1/, t^4 Lecgaclpr Ewe remN <br /> 3. Is the business presently under any Permits? Yes [] No [] <br /> a. State Permit #: <br /> b. CRWQCB Discharge Requirement # <br /> C. County Permit#: F" P Pr r-rl 7 <br /> d. Other: <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PI-IS/EIID Sanitation Permit #: <br /> b. Public Sewer <br /> Name of System: C� � a S�o�/c�D� C �eyr ,�,,.�c< <� ," !'D.S' ..•ire ,(l��y <br /> City Discharge Permit#: A*fltej At.,g;r T .D/5 tic>;R. rox,r+irc'.ma r 2/is1h� <br /> S. Type of Water Supply <br /> a. Name of Pulic II20 System: <br /> b. e We <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 /> EH 22 035 (Rev 4/90) <br />