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. %clic Health Services of San Joaquin County <br /> Environmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> I. Does the business handle lLtzardous Material? Yes No [ ] <br /> a. Type i" <br /> b. Amount: <br /> 2. Does the business generate Hazardous Waste? Yes Q No [ ] <br /> a. Type: <br /> b. Amount generated per month: 'vim /co <br /> C. EPA#: <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 #: <br /> b. CRWOCB Discharge Requirement # <br /> C. CountyPermit#: ii <br /> d. Other. <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PHS/EHD 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 11.0 System: <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 <br /> /Wast e Storage: <br /> EH 22 035 (Rev 4/90) <br /> 0 <br /> �u ste �� <br />