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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Li_ MASTER FILE RECORD INFORMATION FORM - PUBLIC WATER SYSTEM <br /> ® New Public Water System at Existing Facility ❑ New Public Water System and New Facility <br /> Facility ID FA0022347 Program Record ID PRQ5`.69 $ <br /> Facility Address 735 N. Fine Road <br /> (Please check the appropriate description and specify size, number of units and pertinent information) <br /> PUBLIC WATER SYSTEM PROGRAM (4600) <br /> APPLICATION <br /> ❑ New Small Community Water System(SCWS) (4603) Dates of operation to <br /> ❑ New Non-Community Water System (NCWS) (4602) Dates of operation to <br /> ❑ Permit Amendment(4604) <br /> PERMIT <br /> ❑ State Small Water System (4644)5-14 Service Connections <br /> ❑ SCWS(4521) 15-24 Service Connections <br /> ❑ SCWS(4622)25-99 Service Connections <br /> ❑ SCWS(4623) 100-199 Service Connections <br /> ❑ Non-Transient NCWS(4630) Serving the same 25 or more individuals=7180 days per year <br /> ❑Transient NCWS (4633) =>25 Customers/Consumers per day <br /> ❑ Surface Water System (SCWS) (4670) 15-199 Service Connections <br /> ❑ Surface Water System(NCWS) (4671) =>25 Consumers=>60 days per year <br /> ® CURFFL NCWS(4616)—Food Facility without Water/Ice service for customers <br /> Type of Water System Service Area <br /> ❑ Residential Area(131) ❑ Day Care Center(S5) ❑ Hotel/Motel (T6) <br /> ❑ Mobile Home Park(R2) ❑ Other Semi-Residential (S9) ❑ Other Transient Area(T9) <br /> ❑ Other Residential Area(R9) ❑ Recreation Area (T1) ❑ Interstate Carrier(01) <br /> ❑ School (S1) ❑ Service Station (T2) ❑Wholesaler(02) <br /> ❑ Institution (S2) ❑ Summer Camp(T3) ❑ Other area(09) <br /> ❑ Medical Facility(S3) ® Restaurant(T4) <br /> ❑ Industrial/Agricultural(S4) ❑ Highway Rest Area (T5) <br /> Type of Water System Ownership <br /> ❑ Federal Government(1) ❑ State Government(3) ❑ Mixed Public/Private(5) <br /> M Private (2) ❑ Local Government(4) <br /> Type of Water Supply <br /> ®Well(10) ❑Well, Purchased (15) ❑ Lake, Purchased (33) ❑ Spring, Purchased(51) <br /> ❑Well, Stream(11) ❑ Stream, Purchased (24) ❑ Canal (40) ❑ Purchased(60) <br /> ❑Well, Lake(12) ❑ Lake(30) ❑ Canal, Spring (41) ❑ Unknown (70) <br /> ❑Well, Canal (13) ❑ Lake, Canal (31) ❑ Canal, Purchased(42) ❑ Other(99) <br /> ❑Well, Spring(14) ❑ Lake, Spring (32) ❑ Spring(50) <br /> EMERGENCY NOTIFICATION FOR PUBLIC WATER SYSTEM <br /> CONTACT PERSON See 5021 Job Title <br /> Address City State Zip Code <br /> Phone#1: ( ) Phone#2: ( ) Phone#3: ( ) <br /> PROGRAM ELEMENT 4616 FEE 0 ❑APPLICATIONIAMENDMENT FEE <br /> Permit Valid TO INSPECTOR# <br /> ❑ Check# Amount Paid Date Invoice# <br /> ❑ Cash REVIEWED BY: ACCOUNTING OFFICE DATP_: <br /> END 46-03 PWS MASTER FILE-BLUE <br /> 10/12107 <br />