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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Greotness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Natural Synergy, LLC <br /> Facility Address: 24707 South Bird Road, Tracy, Ca. 95304 <br /> Street City Zip <br /> Facility Business Owner Name: Darren D. Mangrum Phone:510-415-2125 <br /> Property Owner Name: Darren D. Mangrum Phone:510-415-2125 <br /> Property Owner Address: 24707 South Bird Road, Tracy, Ca. 95304 <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):3 <br /> 2. Number of employees at the facility per shift: 3 _ Number of shifts: 3 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 5 April 5 July 5 October 5 <br /> February 5 May 5 August 5 ! November 5 <br /> March 5 June 5 September 5 I December 5 <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> Eany I 31 April 30 July 31 October 31 <br /> ry 28/29 May 31 August 31 November 30 <br /> 31 June 30 September 30 December 31 <br /> 5. Number of yearlong residents: 0 <br /> 6. Number of residents per month, if variable: <br /> January 0 April 0 July 0 October 0 <br /> February 0 May 0 August 0 November 0 <br /> March 0 June 0 September 0 December 0 <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 /> i <br /> Facility Business/Property Owner: ����'-"z� Date: <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 />