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0 <br />Public Health Services of San Joaquin County <br />Environmental Health Division <br />BUSINLSS I.ICENSL SURVEY <br />I, Does the business handle Ilazerdous Material? <br />Yes <br />No [ ] <br />Type: � l <br />)%-e n <br />a. <br />b. Amount: �C L> �%- / < <br />v SJff- <br />2 YC,1,6a o, cu ,t - 1�✓-e� .cS'. li r 5� <br />Yes [ ] <br />No [ ] <br />2 Does the business generate Hazmmk is Wage? <br />/� <br />'Type: I 5 <br />At <br />a. It <br />b. Amount generated per month: <br />�^ <br />C. EPA #• er v <br />d, Storage method and time stored on premise:J <br />e. Waste disposal meth: arc <br />3. Is the business presently under any Permits? Yes [ ] No [ ] <br />a. State Permit #: <br />b. CRWQCB Discharge Requirement # <br />C. County Permit # <br />d. Other: <br />4. Type of sewage disposal system�� <br />a. Private Septic System <br />PHS/LHD Sanitation Permit #: <br />b. Public Sewer <br />Name of System: <br />City Discharge Permit #: <br />5. Type of Water Supply <br />a. Name of Putic II20 Sysie= <br />b. Private Wci1 <br />Pl-IS/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 aces ttiv AM) <br />