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SAN J OAQ U I N Environmental Health Department <br /> COUNTY <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: LOCKEFORD MATERIALS <br /> Facility Address: 18303 N HIGHWAY LOCKEFORD 95237 <br /> Street City Zip <br /> Facility Business Owner Name. JESUS E MEZA Phone: 209.224.7040 <br /> Property Owner Name: JESUS E MEZA Phone: 209.224.7040 <br /> Property Owner Address: PO BOX 980 LOCKEFORD 95237 <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): 1 <br /> 2. Number of employees at the facility per shift: 12 Number of shifts: 1 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 20 April 20 July 20 October 20 <br /> February 20 May 20 August 20 November 20 <br /> March 20 June 20 September 20 December 20 <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 20 April 20 July 20 October 20 <br /> February 20 May 20 August 20 November 20 <br /> March 20 June 20 September 20 December 20 <br /> 5. Number of yearlong residents: 0 <br /> 6. Number of residents per month, if variable: <br /> January N/A April N/A July N/A October N/A <br /> February N/A May N/A August N/A November N/A <br /> March N/A June N/A September N/A December N/A <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: <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 />