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r^c . SAN-d O A Q U I N Environmental Health Department <br /> o.T <br /> i, <br /> �. COUNTY---- <br /> Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: E V-O"T�4 EL" CA = Q S 131 <br /> Street City Zip <br /> Facility Business Owner Name: 'C-�It)I�Atny �,"L� Phone:70q -tiiqS- O6S3 <br /> Property Owner Name: `9 kAMA'AX:A' a 'U- Phone: <br /> Property Owner Address: —s' <br /> Street City Zip <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s):-]-- <br /> 2. Number of employees at the facility per shift: I Number of shifts: <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January April July -,-?* October <br /> February May August November <br /> March June Ei September December <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January _ April —,;p July October —f' <br /> February May IN August November .� <br /> March `^ June September December i. <br /> 5. Number of yearlong residents: A� <br /> 6. Number of residents per month, if variable: <br /> January April July October <br /> February May August November <br /> March June 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 D - 13 - ZD <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 />