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Public Health Services of San Joaquin County <br /> Environmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> 1. Does the business handle Ilaardau Material? Yes (� No [] <br /> a. Type: (1,'7s6� - r fig ivos . �i� Or <br /> b. Amount: <br /> 2. Does the business generate Ilazardous Waste? Yes [i]� No [] <br /> a. Type: �Q C�1I / tA)O5 A et (15 <br /> b. Amount generated per month: <br /> C. EPA#: "C-i <br /> d. Storage method and time stored on premise: <br /> C. Waste disposal method: i/u�+� asG� P/�NP/�7 �rU/ YAC <br /> 3. Is the business presently under any Permits? Yes [] No [] <br /> _�- <br /> a. State Permit #: <br /> b. CRWQCB Discharge Requirement #. ' <br /> C. CountyPermit#: C�SINPCt /GPuS-e. <br /> d. Other. — <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PI-IS/EI ID Sanitation Permit #:— - <br /> b. Publicr / 1 <br /> Name off System: <br /> � �/stem: C� Or '1D <br /> City Discharge Permit#: <br /> S. Type of Water Supply y ) <br /> a. Name of Pulic II10 System: CW-7 <br /> ��U✓� �� <br /> b. Private Well —� <br /> PIIS/EHD Well Permit#: /! <br /> Number of Employees b <br /> Distance from septic system(s): /✓A <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 /> Ea 22 035 (an 4M) <br />