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'JOU Environmental Health Department COUNTY - ,r, 9, ,,v ?Au 0 015 0 WATER PROVISION DECLARATION Facility Business Name: GOLDEN STATE TRUCK TERMINAL, LLC Facility Address: 147 E. FRENCH CAMP RD, FRENCH CAMP, CA 95231 Street city Zip Facility Business Owner Name: GOLDEN STATE TRUCK TERMINAL, LLC Phone: 510-565-4559 Property Owner Name: GOLDEN STATE TRUCK TERMINAL, LLC Phone: 510-565-4559 Property Owner Address: 1706 W. WOODWARD AVENUE, MANTECA, CA 95337 Street city Zip WATER PROVISION INFORMATION 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s): 1 WELL.SERVING LANDSCAPE AND PROPOSED GUARD SHACK 2. Number of employees at the facility per shift:Guard= 1/shiftNumber of shifts: Guard =3 shifts/day 3. Total number of employees, customers, and visitors at the facility per month, if variable: January 3 April 3 July 3 October 3 February 3 May 3 August 3 November 3 March 3 June 3 September 3 December 3 VALDE ENTERED REPRE=SENTS EMPLOYEE COUNT PER DAY. DIFFICULT TO ACCOUNT FOR TRUCK DRIVERS ENTERING/LEAVING SITE AS'THEiFaSCHEDULE VAR)ES AND IS DEPEN ENT ON DRIVER'S ROUTE 4. Number of days that total number of customers, visitors and employees frequent the facility per month: January DAILY April DAILY July DAILY October DAILY February DAILY May DAILY August DAILY November DAILY March DAILY June DAILY September DAILY December DAILY 5. Number of yearlong residents: N/A 6. Number of residents per month, if variable: N/A January April July October February May August November March June September December I declare under penalty of perjury that the statements on this application are correct to my knowledge. It is the owner's responsibility to notify this office if the water provision information of the facility changes. Facility Business/Property Owner: Date: r r Signature 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com