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- a to3 h Web., uin.ca.us/thd <br /> 468-X420 • F4X: <br /> ° WATERT� R 5Y STE IDECLARATIOVIECENED <br /> L <br /> Faci';y LORI V 95240 <br /> �. Name 11N. H�GIS' <br /> "'7., ENViiONMENTAI<- <br /> Facility Address: 5cee: <br /> Facility B usincss Own zr Zip C06e <br /> SAME City <br /> Pr4wne' <br /> opt,' Street <br /> 1 off ice <br /> h p building <br /> or ocher copied buildings served by the water <br /> l. Number of houses, mobile homes, 1 . <br /> Y shill g Number of shifts: <br /> f z. Number of ainp3oyees at the facilsry p <br /> Per month if,• ariable. <br /> o:e�np tht it $ <br /> loyees at fac P <br /> _ _ .. .�:-., �. - ..r.l Jul•r- +, _L1.. October <br /> r <br /> Janus �� il. <br /> Fcbrn9ry 11 „�— bcr ' . <br /> lrtartb lope uentthe facilitY <br /> t�tat tete total number of Gustoers,'visitors and em'*Ye�s that fre4 <br /> 4 Number of days �c snore cu�:Crners on b days in 3anuarv, or 25 +/ti days): <br /> exceeds 24 in each month (iearO*tabor <br /> July <br /> p rtl August AlovtaLw 2 <br /> Jtntrar* <br /> } February eta► ". 2 <br /> 2 I 5eptetnber 2 December' <br /> >vlb 1 J use <br /> j. Numbec of yearlong residenu. --3, <br /> 6. Number of residents per mot►th, if variabie:l } Now 0 <br /> Duty 0 <br /> Aa kw0 <br /> 0 <br /> ', Fetnvan' ' May I ', 5eptztnbrr ' 0 <br /> Mares I 0 iut� 'L--0 <br /> yy SI N TNF4�0I0N vision at the facility <br /> Rase check th fbox that best describes the water pxo a <br /> Using the information listed abcrves P tons used by.earlong�or it regularly serves at least 2S yearloa8 rrsi <br /> T t wtu serves a-,least is coattar <br /> persons�tl=e , et7tployees, students) over sir ns�'u (TNC) <br /> y�te well sen-es at least 25 0`the i.c.. customers, v-istors) at least 60 days pw Y <br /> ew <br /> The well ser'es 15 cr more persons <br /> (i.c.,luscs.mobile homes.rtc)and does not serve"Lawater to an ave Of <br /> j 'T'}IE a+Ell serves five to Wy&rpu&out the Yew <br /> :5 individuals drily for wort Chan 60 days out of tpr}car {State Sraali) <br /> .reqularly serves 24 or less individuals <br /> The well serves y C m ��1W�� • <br /> ' that th statemtnts on this applicatt=� � ! w <br /> gt <br /> I(We) decl art under penalty of pertluri d,is o gee ;f the operation of the facility chanes to the e>s�d nO <br /> 4t is the owner's responsibility to notify <br /> mel is a wneT nt definition of a publto L I1�C then .ndicated on this form• <br /> Date: r S"2� <br /> s <br /> WSW men <br /> l=acllln B , LO �. , tt <br /> �xfl�-cos I <br />