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U 0 0 8 <br /> S A N J O A Q U I N Environmental Health Department <br /> --COUNTY-- <br /> Greatness <br /> COUNTY--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 City Zip <br /> Facility Business Owner Name: Same _ Phone: 209-565-982 <br /> Property Owner Name: Phone: <br /> Property Owner Address: <br /> Stree t CIH Zip <br /> WATER PROVISION INFORMATION <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 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 April July 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 /> Digitally signed by Parry Dalzell 4/28/21 <br /> Facility Business/Property Owner: Date:2021.04.2814:43:14-07'00' 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 />