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a N.;: 0 Q ► . Environment Health Deparfnictit <br /> ! COUNTY <br /> Grecjino,s gro-ws liercr, <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: 4jtlwp <br /> Facility Address: V=6p �E2w t- 1' WD( <br /> S�t"red City Zip <br /> t <br /> Facility Business Owner Name: C Z S —WIC-0/1 1 Phone: Lo 9 -�,Y <br /> Property Owner Name: CAI<-e(; Wi` e"t h Phone: <br /> Property Owner Address: 0 �f �!n '7r 9s'z <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):—L- <br /> 2. Number of employees at the facility per shift: ' kkkW k, Number of shifts: f <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January April ,... July October r <br /> February May ?j August November <br /> March June September December .,w� <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 31 April 0 July October <br /> February 2S May 3August 3 November p <br /> March 31 June 36 September 3C) December �I <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: 4Date: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicelid.coni <br />