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Q'P SANsJ0AQUIN Environmental Health Department <br /> �" !•'_;'._: <br /> COUNTY— <br /> C' <br /> '141FOV <br /> OUNTYc'94,FOV Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: WAkeSUJ4-4 WAI 'ASPOPT5 /c� <br /> Facility Address: qN 5 W. !"\O 550Ti�' _ !�• L4-Ae h 33 0 <br /> Street p City Zip <br /> Facility Business Owner Name: -e-�-t- I' G ItiNu Cor L;AJ Phone,?©gj- 6.3--a3a6 <br /> Property Owner Name: I •\C9 / am'c ofe-1 . t�TJ <br /> Phone:20 OF <br /> Property Owner Address: P-0.3c* J'f;q G-4 IMDS L 5-fan <br /> Street City f 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: 3 Number of shifts: 1 <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 I C, 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 11 November <br /> March June September December <br /> 5. Number of yearlong residents: N/A <br /> 6. Number of residents per month, if variable: <br /> January N April N/A July N/A October N/A <br /> February N/A May N/A August N/A November N/A <br /> March N/A June N/A September N/A December N/A <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: <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 />