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SAN JOAQUIN Environmental Health Department <br /> --COUNTY <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Lenzi Incorporated <br /> FacilityAddress: 9150 E State Route 12 Lodi 95240 <br /> Street City Zip <br /> Facility Business Owner Name: Cliff Lenzi Phone: 209 310-2252 <br /> Property Owner Name: <br /> Cliff Lenzi Phone: 209 310-2252 <br /> Property Owner Address: <br /> _ - Z; - <br /> 9150 E State Route 12 Lodi 95240 <br /> _ <br /> Street City P <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: 12 Number of shifts: _ <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 12 April July 12 October 12 <br /> 12 <br /> February 12 May 12 August 12 November 12 <br /> March 12 June 12 September 12 December 12 <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 14 April 14 July 14 October 14 <br /> February 14 May 14 _August 14 November 14 <br /> March 14 _June 14 September 14 December 14 <br /> 5. Number of yearlong residents: 0 <br /> 6. Number of residents per month, if variable: <br /> JulyOctober <br /> January April <br /> February May August November <br /> LMarch I 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 /> Facility Business/Property Owner: ate: Z j <br /> signal ro f / <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />