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<br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />(PA 210009; <br />WATER PROVISION DECLARATION <br />Facility Business Name: -zip <br />Facility Address: 1 -/-17 t... 1, A TI-t STAE€Fr irtge , ci; ci -.109 <br />Street City <br />Facility Business Owner Name: E. L .Wtf2.7-1•3611-53 LL C_. Phone: (41 -74.Z(Dip <br />Property Owner Name: St•rnAe- Phone: ont4€ <br />Property Owner Address: 2, Rime <br />WATER PROVISION INFORMATION <br />Street City Zip <br /> <br />Number of houses, mobile homes, or other occupied buildings served by the water well(s): <br />Number of employees at the facility per shift: Number of shifts: <br />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 />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 />Number of yearlong residents: <br />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: <br /> <br />Date: 61(112.1 <br /> <br />Sigrtüe <br /> <br />1868 E. Hazelton Avenue Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 www.sjcehd.com