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S A N J Q A Q U I N Environmental Health Department <br />COUNTY <br />Grentness cjrosys here. M 2 0 00 e 5 <br />WATER PROVISION DECLARATION <br />Facility Business Name: Zt p 50cw-8 S-rr 66 <br />Facility Address: _'1 w 11TH STY 1P-AZY , GS 9ys-&40t1 <br />Street City Zip <br />Facility Business Owner Name: _E.L.' -rt4 d.s3 LL C_ Phone: 415 ?Go -rtiSZ <br />Property Owner Name: brftt7 Phone: 56we <br />Property Owner Address: b <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: 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 September December <br />4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br />January April July October <br />February May August November <br />March June September December <br />5. Number of yearlong residents:CD <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: S1It tz I <br />Sig ure <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 I www.sjcehd.com