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WATER PROVISION DECLARATION <br /> Facility Business Name : roiA r't � ��� ' l r� ��s <br /> C74 lie <br /> Facility Address : <br /> Street City Zip <br /> 3 to <br /> Phone : 1�; -- oz3 z <br /> Facility Business Owner Name : t 0 j / <br /> Property Owner Name : L1 1, V;, , Phone : J <br /> Property Owner Address : toll <br /> "n <br /> S eet 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 : <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 i / November Tie <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 � July October <br /> February May � 'i 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 /r' October <br /> February ' May r� August , f' NovemberTWA <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 : ,e' - � f ✓ - � --- % '� Date : <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . sjcehd . com <br />