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SAN J OAQ U I N Environmental Health Department <br /> ------ C OU N T Y--- <br /> pA2 x. 00 178 <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: SPLOLON ftv0� <br /> Facility Address: _P.0' Dox Sim "Tw o P Cr4 <br /> Street city Zip <br /> _Facility ausiness_C)Wner Narrae. (� ., tI /�,eF�P i7e' l 1Jc phone,2 Sz%� yo <br /> . Property Owner Name: M�Ss j !� Ss�c,A -i � G� Phone: -C)';,1?3-5-e:S' <br /> Property Owner Address: `� i o>( f q 29 LA`17i-,<c--P Cil 23- T-4 u <br /> T' Street city Zip <br /> .WATER PROWS"WFOFMAD" <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: NIA Number of shifts:_N�- <br /> :3.. Tsatal number-of T- Md vis at the fw11ity per tenth;if variable. <br /> January I 1`f/A I April July October <br /> February May August November <br /> March l June September December <br /> 4. Number of days that iotal nurnber of customers,visitors and employees freque.rd 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 i. ,lune September December ; <br /> 1 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 /> FacilityBusiness/Property Ger,` ����� Date. �71Z 6/P-/ <br /> Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />