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n�N <br /> 10 <br /> °°1- <br /> � SAN sd0AQUIN Environmental Health Department <br /> COUNTY <br /> — <br /> 1 <br /> 6F6 Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: G & H Dairy <br /> Facility Address: 16996 Sexton Road, Escalon, CA 95320 <br /> Street City Zip <br /> Facility Business Owner Name: Gerard Van de Pol Phone: (209) 765-6225 <br /> Property Owner Name: Gerard Van de Pol Phone: (209) 765-6225 <br /> Property Owner Address: 16996 Sexton Road, Escalon, CA 95320 <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):6 <br /> 2. Number of employees at the facility per shift: 8 Number of shifts: 2 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 19 April 19 July 19 October 19 <br /> February 19 May 19 August 19 November 19 <br /> March 19 June 19 September 19 December 19 <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 31 April 30 July i 31 October 31 <br /> February 28 May 31 August 31 November 30 <br /> March 31 June 30 September 30 December 31 <br /> 5. Number of yearlong residents: 6 <br /> 6. Number of residents per month, if variable: <br /> January 6 April 6 July 6 October 6 <br /> February 6 May 6 August 6 November 6 <br /> March 6 June 6 September 6 December 6 <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: r Date: ^'J 2� <br /> S' nat e <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />