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0A.2I u 00 811 <br />S A N yid 0 A Q U IN Environmental Health Department <br />-COUNTY <br />Greatness grows here. <br />WATER PROVISION DECLARATION <br />Facility Business Name: Central Valley Baptist Church <br />Facility Address: 10948 S. Airport Way Manteca Ca. 95336 <br />Street <br />Facility Business Owner Name: Same <br />Property Owner Name: <br />Property Owner Address: <br />WATER PROVISION INFORMATION <br />City Zip <br />Phone: 209-565-982 <br />Phone: <br />Y <br />1. Number of houses, mobile homes, or other occupied buildings served by the water well(s): <br />2. Number of employees at the facility per shift: Number of shifts: <br />3. Total number of employees, customers, and visitors at the facility per month, if variable. - <br />January April July October <br />February May August November <br />March June September December <br />4. Number of dans 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 <br />April <br />July <br />October <br />February <br />May <br />August <br />November <br />March <br />June <br />September <br />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 />Digitally signed by Parry Dalzell 4/28/21 <br />Facility Business/Property Owner: Dala:zoz,.oa.ze,a:a3:,a-o7 Date: <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 />