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SAN 10AQUIN Environmental Health Department <br /> COUNTY <br /> } LL, nI \UJ o <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Sri Veda Vidya Peetham <br /> Facility Address: 21199 San Jose Rd Tracy CA 95304 <br /> Street City Zip <br /> Facility Business Owner Name: Venkateshwar Chintapalli, Manikya Prabhuo Phone:925-980-9257 <br /> Property Owner Name: Venkateshwar Chintapalli, Manikya Prabhu Salve Phone:925-980-9257 <br /> Property Owner Address: 21199 San Jose Rd Tracy CA 95304 <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):1 <br /> 2. Number of employees at the facility per shift: 2 Number of shifts: 2 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 30 April 30 July 30 October 30 <br /> February 30 May 30 August 30 November 30 <br /> March 30 June 30 September 30 December 30 <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 10 April 10 July 10 October 10 <br /> February 10 May 10 August 10 November 10 <br /> March 10 June 10 September 10 December 10 <br /> 5. Number of yearlong residents: 2 <br /> 6. Number of residents per month, if variable: <br /> January 2 April 2 July 2 October 2 <br /> February 2 May 2 August 2 November 2 <br /> March 2 June 2 September 2 December 2 <br /> !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: I:fA- /\ Date: G <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 />