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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 11azardous Material? Yes [ No [ ] <br /> a. Type: <br /> b. Amount: cz vo Z 62L <br /> 2. Does the business generate Hazardous Waste? Yrs [ ] No [] <br /> a. Type: 0(1,-- <br /> b. Amount generated per month: qD0 C—AL- <br /> C. EPA#: 4ir c. f'U tj cLDSE or ESG,°-v c j <br /> d. Storage method and time stored on premise: pv (rr#L't Bloc✓ �r �E <br /> e. Waste disposal method: �1JVIR�t�!/�t�1�ITL �' Q,�lpF[T <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/EFID Sanitation Permit #: <br /> b. Public Sewer <br /> Name of System <br /> City Discharge Permit#: <br /> 5. Type of Water Supply <br /> a. Name of Pulic H2O System: Gr�Y 0 iC S'i��-K�a A1 <br /> b. Private Well <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 />