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`,��`F�'� SAN'�JOAQUIN Environmental Health De awtiToent <br /> ��H�`�'�:.'� OOU NTY p <br /> bf'F$"`%�' Erectness grows fierce. <br /> WATER PROVISION DECLARATION <br /> Facility Business Names: `TOP `A3a w•q-y� �T'{zln_Q.��.,nq .s itt e <br /> Facility Address: �->jt�' t.S 1!�'`ST• cA�a s3o Ly <br /> p� � cly cep <br /> Facility Business Owner Name: /.>pr�W ND'E✓(Z uQ-l.t t� Phone- ZOq -God-aa/SC <br /> Property Owner Names: (�.1?rt�� ND��-(L IL�vt�_ Phones:2d-1 �C�a�-oo! rQ <br /> Property Owner Address: Sy2� w 1/�ST ��Ra/-if C1P 4� <br /> steal cb cep <br /> WATER PROVISION INFORMATION <br /> 7. Number of houses, mobile homes, or other occupied buildings served by the water well(s): O � <br /> 2. Number of employees at the facility per shift: 06� Number of shifts: B N�©N�-� <br /> 3. Total number of employees, customers, and visitors at the facility per month, it variable: <br /> January April July Octobs <br /> February May Augus[ November tj <br /> MarcM1 Junes 8aptember December <br /> 4. Number of days that total number of customers, visF[ors and employees frequent the facility per month: <br /> January April July Oc[ebar <br /> February May August Novambar <br /> March Junes 8eplember December <br /> 5. Number of yearlong residents:_L7 �/ <br /> 6. Number of residents par month, If variable: <br /> January Apfli JuIY October <br /> February p,'j May AUBuet Novambar <br /> March B June 8eptambar December <br /> /dec/are under panatty of perjury that the statements on thJs app/kation are correct tc my Know/edg®. /t is the <br /> owner's responsibi/ity to notify thfs office if the water provision information of the fact/ity changes. <br /> Facility Business/Property Owner: _ _ _ _ RQl ls9 l'tYl�e� Irate: �'"S J a3� 2� <br /> sg.,amra <br /> �868 E. Hazelton Avan ue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 � www.sjcand.com <br />