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S A N J O A Q U I N Environmental Health Department <br /> _...COU NTY...__.._..... <br /> r rectness aro�;s ore. <br /> J %2100214WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: 3127 E. Fremont St. Stockton, CA 95205 <br /> Street City Zip <br /> Facility Business Owner Name: Alfonso OcampoNictor Aranda Phone: 209-518-8883 <br /> Property Owner Name: Vlcto r Janda _ Phone: <br /> Property Owner Address: 1318 E. Scotts Ave. Stockton, CA 95205 <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 I October <br /> February May August November <br /> March June September December <br /> 5. Number of yearlong residents: none <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 /> 1 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 /> / v A <br /> Facility Business/Property Owner: `' , Date: 3 - 264 it <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 />