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04/10/2002 09:37 20 7433 FIFTH FLOOR . I PAGE 03 <br /> epi r <br /> WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS: I I o7 N, _4, y y <br /> STREET <br /> CITY �P <br /> FACILITY BUSINESS OWNER: �� i U,tcsk t-� , P/CS1 c)th <br /> NAME <br /> PROPERTY OWNER: Jccwcs IUcXc � dI p✓I f „�*� C / �P � <br /> NAME <br /> Please complete the following: <br /> 1 Number of houses, mobile homes, or other occupied buildings served <br /> by the water well(s): I <br /> 2 Number of employees at the facility per shift: _ Number of shifts: <br /> t <br /> 2 Number of employees at the facility per month, if variable: <br /> JAN Z FEB 2 MAR APR 17 _ MAY _ JUN <br /> JUl f � . AUG SEP OCT Z Z- NOVDEC <br /> 4 Number of yearlong residents: <br /> 5 Number of residents per month, if variable: <br /> JAN FEB MAR APR MAY JUN <br /> JUL AUG SEP OCT NOV DEC <br /> Using the information listed above, please check the box that best describes the water provision at the facility. <br /> 00 The well serves at least 15 connections used by yearlong residents <br /> Or it regularly serves at least 25 yearlong residents. (Community) <br /> EIC The well serves at least 25 of the same persons(i.e. employees, students)over six months per year <br /> (NTNG) <br /> 07 The well serves 25 or more persons (not the same persons, i.e. customers,visitors) at least 60 days per <br /> year. (TNC) <br /> ❑❑ The well servesfive to 140 cnections (i.e. houses, mobile homes, etc.)and does not serve water to an <br /> average of 25 individuals daily for more than 60 days out of the year. (State Small) <br /> u The well serves less than 5 connections and regularly serves 24 or less individuals dally though out the <br /> year. <br /> I hereby declare that the above rmation is accurate and true, <br /> FACILITY BUSINESS OWNER —2 <br /> UREZ DATE <br /> PROPERTY OWNER: <br /> SIGNATURE DATE <br /> Rx time:04/09/2002 20:34 Rx No.:636 P.003 <br />