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?ublic Health Services of San Joaquin Counryi <br /> Environmental Health Division <br /> BUSINESS LICENSE SURVEY <br /> 1. Does the business handle Hazardous Material? Yes No [ J <br /> a. Type: t ( �/ �.a <br /> b. Amount: <br /> 2 Does the business generate FLa ardour Waste? Yes No [ ] <br /> a. Type: <br /> b. Amount generated per month: <br /> C. EPA#: C/�1-- r p o 0 D oZ <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. CRWQCB Discharge Requirement # <br /> C. County Permit <br /> d. Other. <br /> 4. Type of sewage disposal system <br /> a. Private Septic System <br /> PHS/EI-ID 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 II20 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 Waste Storage: <br /> 22 035 (Rev 4/90) 5 s D 51 <br /> 3 <br />