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m�oh co SANsJOAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: .9-at&TM HIAI,>a 6"(,7UghJ- 6e1nff7G10//z/ C 07re C S HCCO <br /> Facility Address: L- M roPoprivv t*,-ve CA g3Z-1 2- <br /> Street City Zip <br /> Facility Business Owner Name: kfCPhone: ) 51 $ -- 13q-0 <br /> Property Owner Name: SNCCC-C Phone:(Zz,,i� 5/$- /34.0 <br /> Property Owner Address: 5tVnc ft-s #&)41E <br /> Street City 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: �j/A <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January /.Z April /0-1,7 July /L)-1 Z October /p --/ <br /> February /0 —12 May / 0-121 August / _12 November 10-12— <br /> March <br /> v--12— <br /> March /p 12 June In _12 September lo-17— December 10-1 Z <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 1 May / August November 1 <br /> March I June ( September ( December / <br /> 5. Number of yearlong residents: <br /> 6. Number of residents per month, if variable: <br /> January / April 1 July ( October fA <br /> February ( May ( August J 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 /> Facility Business/Property Owner: 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 />