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04/25/05 01:F` P.002 <br /> 12/03/2004 13:58 2094L .33 FIFTH FLOOR PAGE 02 <br /> WATER SYSTEM DECLARATION <br /> FACILITY ADQRESS: x7393 err<�rey 120 JL o y aTT-, C A 9,f�90 <br /> srrrFEr ZIP <br /> FACILITY BUSINESS OWNER: JOSL-r-H <br /> NAME <br /> S PROPERTYOWNER: W Osj 0-6 4'--ats #4 k-0 <br /> NAML <br /> Ploaee complete the following <br /> Number of houses,mpbile homes,or other niVed buildings served by the water well(s): <br /> I Yaw. /:-"J I I ---Ir—T-.. i <br /> Number of ampbyees at the Facility,per shift: Number of shifts: <br /> Number of enTp"es at the facility per month,It variable, <br /> JAN FEB MAR APR MAY JUN <br /> JUL AUG SFS' OCT NOV DEC <br /> Number of days that the total number of custvmam,visitors and employees that frequent the feririty oKC000S 24 <br /> in each month: <br /> (i.e.25 or more customers on 6 days in January,or 26+/6 days) <br /> JAN FEB MAR APR MAY JUN_ <br /> JUL AUG SEP OCT NOV DEC <br /> Number of yearlong residents: ___.____ <br /> Number of residents per month, If variable. <br /> JAN FEB MAR APR MAY JUN <br /> JUL AUGSEP OCT NOV DEC <br /> Using the information listed above,plane@ check the box that best describes the water provision at the facility. <br /> ❑p The well selves at least 13 Connections used by yearlong residents <br /> Or it regularty,serves at least 25 yearlong residents.(Community) <br /> 03 The well serves at least 25 of the sam@ persons(f.e.employees,students)over six months per year <br /> (NTNG) <br /> ❑q The well serves 25 or more persons toot the same persons,i.e.customers, visitors)at least 60 days per <br /> yeas (TNC) <br /> CX The well serves five to 14 conneobor)F(i.e. houses,mobile homes,eta)and does not serve water to an <br /> average of 26 mdiwduals dorryfor more than 60 deys out of the year. (State Smell) <br /> 00C The well serves less than 5 connections and regularly serves 24 or less individuals daily throughout the <br /> year. (Private water system). <br /> I(We)declare under penalty of perjury that the statements on this applloattdn are correct to my(our)knowledge. <br /> It is the owner's responsibility to notify this oRlce 0 the operation of the facility changes to the extent it now meets a <br /> different definition of a public water system then Indicated on this form. <br /> IT <br /> FACILY BUSINESS/PROPERTY OWNER. f JOS <br /> SIGNATURE DATE <br />