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DECLARATION (Nontransient-Noncommunity) I> (name of owner or legally authorial representative) declare that I understand the definition of a public water system, as defined in the California Health and Safety Code (CH&SC), Division 104, Part 12, Chapter 4 (California Safe Drinking Water Act), Article 1, Section I I6275(h),to mean that a public water system is "a system for the provision of water for human consumption through pipes or other constructed conveyances that has 15 or more service connections or regularly serves at least 25 individuals daily at least 60 days out of the year." Furthermore, I understand the definition of a nontransient-noncommunity water system, as defined in Section 116275(k), to mean "a public water system that is not a community water system and that regularly serves at least 25 of the same persons over 6 months per year." Furthermore, I declare that I understand that Section 116275(e) defines human consumption as "the use of water for drinking, bathing or showering, hand washing, or oral hygiene." Furthermore, I declare that I understand that Section 116725 of the CH&SC states that "Any person who knowingly makes any false statement or representation in any application, record, report, or other document submitted, maintained, or used for purposes or compliance with this chapter (California Safe Drinking Water Act (AB 2995)), may be liable for a civil penalty not to exceed five thousand ($5,000) for each separate violation or, for continuing violations, for each day that violation continues." In addition, Section 116730 of the CH&SC states that violators may be prosecuted in criminal court and upon conviction,be punished by a fine of not more than $25,000 for each day of violation, or by imprisonment in the county jail not to exceed one year, or by both the fine and imprisonment. In recognition of the above, declaring that I understand the definition of a public water system and the penalty for giving false information, I declare that my facility, (name of system) does not meet the definition of a public water system because it does not serve more than 24 People more than 59 days out of the year. Date Signature