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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> l�rec,nc,5s R'. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: TBD <br /> Facility Address: 15314 N Thornton Rd Lodi, CA 95242 <br /> Street City Zip <br /> Facility Business Owner Name: TBD Phone: <br /> Property Owner Name: Highway 12 Investors, LLC and Lilval Properties, Ltd Phone:209-490-2650 <br /> Property Owner Address: 1203 N. Grant St. Stockton, CA 95202 <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: 3 Number of shifts: 1- 10 hour <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 <br /> February May August November <br /> March June September December <br /> 5. Number of yearlong residents: <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 /> 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: I �''`' Date: <br /> L/-t <br /> 2Z <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 />