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Mar-17-2004 12:28 From-NATL COLD--'sORAGE 9545643166 T-250 P-002/002 F-262 <br /> unu1 vvrsMUJAN %—VU1\1I 1 <br /> ENVVMONMENNAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,P Floor, Stockton.CA 95202-2708 <br /> (209)468-3420■'Fax:(209)464-0138• Web.Www.co.sart-joaquinxa.us/ehd <br /> WATER SYSTEM DECLARATION <br /> Facility Name: <br /> Facility Address- Dk,.,e T_ "Cv r-A 9S�?6 <br /> Banat City Zip Code <br /> Facility Business Owner; <br /> Property Owner: ►.:��s -- :-�t. !J 5 ,,.�A�_ _ <br /> t �, Zip - <br /> �8�6 E. 4A�.1,«.1 PRO( BIv)S,.;ie:3oo C Z Cosa <br /> FACILITY INFORMATIO <br /> 1. Number of houses,mobile homes, or olhher occupiedbum gs served by the water well(s): 3 <br /> 2. Number of employees at the facility per shift:e— S Number of shifts: <br /> 3. Number of employees at the facility per month,if variable: <br /> January April Jtdy October <br /> Ifebrua May August November <br /> Martb Juue September December <br /> 4. Number of days that the total number of customers,visitors and employees that frequent the facility <br /> exceeds 24 in each month(i.e.,25 or more customers on 6 days in January,or 25-r/6 days): <br /> .tanoa April July October <br /> Febrou ry May Augult November <br /> March June September December <br /> 5. Number of yearlong residents:_&Z4 <br /> 6. Number of residents per month,if variable: A,11A <br /> January April July October <br /> Febraery May August I November <br /> 1yj June September December <br /> WATER MOUSION INFORMATION <br /> ?Jsittg the information listed above,please check the box that best describes the water provision at the facility: <br /> ❑ The well serves at least 25 connections used by yearlong LgidmU or it regularly serves at least 25 yearlong resldonts <br /> ❑ The w 4l serves at least 25 of the¢1g persons(Le.,employees,students)over six months per year(NTNC). <br /> [] The well serves 25 or mare pennons(not-the same aeriogs.i.e,,customers,victors)at least 60 days per year(TNG'). <br /> ❑ 'aha well serves fbye(c)to 14 cannActions(i.e.,houses,mobile hones,etc)and does not serve water to as average Of <br /> ZS individuals daily for more tbatt 60 days out of the year(State Small). <br /> [(The Weil serves less than five(51 connections aad regularly serves 24 or less individuals daily through out the year- <br /> I(We)declare under penalty of perjury that the statements on this application:arc correct to my(our)knowledge. <br /> It is the owner's responsibility to notify this office if the operation of the facility changes to the exzmt it now <br /> meets a different definitioxt of a public water system then indicated on this form. <br /> Fect7ity Business/Property Owxter: Date: <br /> sf�,9:ate <br /> LIZ2Y— <br /> MW ab az-0os <br /> wau�•sy:t��le�paR <br /> 2rl�rtooa <br />