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to Environmental 145' LDe artment <br /> SAN. IOAQUIN p <br /> f COUNTY <br /> Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: !�p y-i qO<C C.ot_,,nyaA Lluhr,\u�1 qS ab y <br /> street city zip <br /> Facility Business Owner Name: Nip Kon&w Ck Phone: (ao rA�S ay -o cd a7 <br /> Property Owner Name: k)g,& MoMomo,A a,a_ /�r�c�6. A��Suwvk„r� Phone: (a -),j) 53'a -oTa� <br /> Property Owner Address: �_ kXWe 'aaY\�'1, <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): 0 <br /> 2. Number of employees at the facility per shift: 1- Number of shifts: a <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 October r��hvown <br /> February May August November <br /> March June September December <br /> 5. Number of yearlong residents: u,N\w,nown <br /> 6. Number of residents per month, if variable: uMhr.o"N <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: Date: aU a a. <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 />