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Sr J OA Q U I N Environmental Health Department <br /> C.I'D U, TY_... ... <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Tru by Hilton - Lodi <br /> Facility Address: 6125 W Banner Street, Lodi CA 95242 <br /> Street City Zip <br /> Facility Business Owner Name: Pp)< i--i p J 'TALT T-)` Phone: 9-.0 q - ti R — G-719. <br /> Property Owner Name: P())< i jPhone: .(209)483-0450 <br /> Property Owner Address: 1 '70 1 l� i-.E N0l\1 1 6 'f- (5 TCS C k7Q T. CA — 952r <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: 2-6 Number of shifts: 3 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January April July October <br /> February May l August November <br /> March l 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 1 <br /> February I _ May _ August November <br /> March June i 1 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: ; Date: E _d . <br /> Signature <br /> 1,968 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcohd.com <br />