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SAN JOAQUIN Environmental Health Department <br /> COk-IN1Y <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: VEST 14 LLC <br /> Facility Address: 5550 E. Cherokee Road, Stockton CA 95215 <br /> sliver 04Y ZP <br /> Facility Business Owner Name: VSSI 14 LLC Phone: 484-5342222 <br /> Property Owner Name: Scannavino Properties LLC Phone: <br /> Property Owner Address: 5463 Cherokee-Road, Stockton CA 95215 <br /> Street_ Cly Zip <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s):0 <br /> 2. Number of employees at the facility per shift:_0 Number of shifts: 0 <br /> 3. Total number of employees, customers,and visitors at the facility per month, if variable: <br /> January 2 April 2 July 2 October 2 <br /> February 2 May 2 August 12 November 2 <br /> March 2 June 2 T September 1 2 December !2 <br /> 4. Number of days that total number of customers,visitors and employees frequent the facility per month: <br /> January 1 April 1 T July 1 October 1 �� <br /> February 1 May 1 August 1 November 1 <br /> j - - — �- — C <br /> March 1 ( June 11 -, September 1 December 1 - <br /> 5. Number of yearlong residents: o <br /> 6. Number of residents per month, if variable: <br /> January 0 April 0 July 0 october lo <br /> February 10 May 0 Au9us► 0 November 0 <br /> MarchT0 June 0 September 1 0 Y �— —i December 0 <br /> - 1 - 1---__ .. <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 Owner:4� � Date: I Y- 3-0 <br /> Signature <br /> 1868 E. Hazelton Avenue j Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwwa.sjcehd.corn <br />