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..pUIN�•... <br /> SAN )Q Q Q Q N Environmental Health Department <br /> COUNTY <br /> ,c <br /> Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: — La — <br /> Facility Address: toy'e-n2gn15 30 <br /> Street -9131 Zip <br /> Facility Business Owner Name:3&-A n P-Anc)'A Phone(aeAQ-49& t <br /> Property Owner Name:Cine 'Q�q(Aic &acdk Phone( <br /> Property Owner Address: 4'1Vj , Lau's Dr. Qz- & 3�Q Qsap°} <br /> Street city Zip <br /> WATER PROVISION INFORMATION <br /> 1. NLznber of houss, mobile homes or other cuie bui din s served by the water well(s): <br /> Q Camp hems*-r ©�� <br /> V b n c3o S r e <br /> 2. Number of employees at the facility per shift: (p Number of shifts: <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable:Re�LVkY—'ernes <br /> January 50 April l July 0-z>1 October <br /> February a May q August sccy November <br /> March June (U September L�nDecember <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January April July October <br /> February May August November <br /> March June September December <br /> 5. Number of yearlong residents: �- <br /> 6. Number of residents per month, if variable: <br /> January 1 April July 1 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 O ner ,', <br /> � Date: 10 <br /> Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />