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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> — <br /> %'Z <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: DEHAL INC. <br /> Facility Address: 11100 & 11140 S. MANTHEY ROAD LATHROP 95330 <br /> Street City Zip <br /> Facility Business Owner Name: INDERJIT DEHAL Phone: 408-896-0408 <br /> Property Owner Name: INDERJIT DEHAL Phone: 408-896-0408 <br /> Property Owner Address: 2404 LOTUS WAY TRACY 95376 <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: 0 Number of shifts: 0 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 0 April 0 July 0 October 0 <br /> February 0 May 0 August 0 November 0 <br /> March 0 June 0 September 0 December 0 <br /> 4. Number of days that total number of customers,visitors and employees frequent the facility per month: <br /> January 0 April 0 July 0 October 0 <br /> February _0 May 0 August 0 November 0 <br /> March 00 June 0 September 0 December 0 <br /> 5. Number of yearlong residents: 0 <br /> 6. Number of residents per month, if variable: <br /> January 0 April 0 July 0 October 10 <br /> February 0 May 0 August 0 November 0 <br /> March 0 June 0 September 0 December 0 <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: -��1— <br /> Signature <br /> 1868 E. Hazelton Avenue 1 Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.00m <br />