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12-10-'04 15:45 FROM-DILI R; MURPHY 1-209-334-0723 T-105 P02/02 U-224 <br /> / 12/01/2004 16: 46 20946b-,33 FIFTH FLOOR PAGE 02 <br /> WATER SYSTEM DE=CLARATION <br /> FACILITY ADDRESS: 16299 E. Hwy 26 Linden 95236 <br /> STREET CITY ZIP <br /> FACILITY BUSINESS OWNER: Mid Valle y AG <br /> NAME <br /> I <br /> PROPERTY OWNER: R&J Dondero <br /> NAME <br /> Please complete the following: <br /> Number of houses, mobile homes, or other occupied buildings served by the water well(s): 1 <br /> Number of employees at the facility per shift: 1... 15 Number of shifts: 1 <br /> Number of employees at the facility per month, if variable: <br /> JAN 10 T„ FES 10 MAR 10 APR 12 MAY 15 JUN 1S <br /> JUL 15 AUG 15 SEP 15 OCT 12 NOV 10 DEC 10 41� <br /> Number of days that the total number of custortters,visitors and employees that frequent the facility exceeds 24 <br /> in each month: 'yl <br /> (i.e,25 or more customers on 6 days in January, or 25+/6 days) <br /> JAN 0 FER, MAR,o APR 0 MAY 0 JUN <br /> JUL 5 AUG 5 SEP 0 OCT 0 NOV__L_ DEC 0_ _ <br /> Number of yearlong residents; <br /> Number of residents per month, if variable.- <br /> JAN <br /> ariable:JAN 1 FEB 1 MAR 1 APR 1 MAY t JUN <br /> JUL 1_ AUG 1 SEP 1 OCT_.L_ NO% 1 DEC_ <br /> Using the information listed above, please check the box that best describes the water provision at the facility, <br /> tip The well Serres at least 15 connections used by yearlong residents <br /> 4r it regularly serves at least 25 yearlong residents. (Community) <br /> C2D The well serves at least 25 of the same persons (i.e. employees, students)over six months per year <br /> (NTNG) <br /> 00 The well serves 25 or more persons(not the seme_Rer*pns, i,e.customers,visitors)at Ieast 60 days per <br /> year_ (TNC) <br /> dp The well serves tf ve to 14 connections(i.e.houses, mobile homes, etc.)and goes not serve water to an <br /> average of 25 individuals daily for more than 60 days out of the year.(State Small) <br /> ED 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 application are correct to my(our)knowledge. <br /> It is the owner's responsibility to notify this office if the operation of the facility changes to the extent 1t now meets a <br /> different definition of a public water system then indicated on this form. <br /> FACILIV allSINESSI PROPERTY OWNER: n 9 )°Z_9-0 Ll <br /> SIGNAT RE DATE <br />