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S A N . OA Q U IN Envy rOnment�l Health Department <br /> CI'D U QTY............. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Tru by Hilton - Lodi <br /> Facility Address: 6125 W Banner Street, Lodi CA 95242 <br /> Street City Zip <br /> Facility Business Owner Name: PD)< H p J TAL`1 T-)` Phone: 2_.Cq - �i R3 — G-7)9 <br /> Property Owner Name: �K �-jC�S}3-r- 7-8 LT- -/ Phone: �2os�483-o4so <br /> Pr <br /> Property Owner Address: 737 l i-.E N0l\1 j Ck-RD0 9520 <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):0 <br /> 2. Number of employees at the facility per shift: 2-6 Number of shifts: 3 <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 Jufy October 1 <br /> February _ May _ August November <br /> March June 7 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 t 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: d <br /> Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.coin <br />