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i ouiN�, <br /> c°,x SA N d 0 A Q U I N Environmental Health Department <br /> 1 t COUNTY <br /> Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Forward Landfill <br /> Facility Address: 9999 S Austin Rd <br /> street city Zip <br /> Facility Business Owner Name: Forward Inc Phone:(209) 982-4298 <br /> Property Owner Name: Forward Inc Phone: <br /> Property Owner Address: 1145 W Charter Way <br /> Strce; City Zip <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s):2 <br /> 2. Number of employees at the facility per shift: 15 Number of shifts: 2 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January April I July October j <br /> February May August November <br /> March June—[— September December { <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 50 April 50 July 50 October 50 l <br /> February 50 I May 50 August 50 November 50 <br /> March 50 June I 50 September 50 December 50 <br /> 5. Number of yearlong residents: 0 <br /> 6. Number of residents per month, if variable: <br /> January April July October <br /> February May I August November <br /> March June I September December <br /> I declare under penalty of perjury that the statements on this application are correct to my knowledge. It is the <br /> owner's responsibility to notify this office if the water provision information of the facility changes. <br /> Facility Business/Property Owner: Date: 1/17/2023 <br /> Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />