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ENVIRONMENTAL HEALTH DEPARTMENT <br /> pQul" SAN JOAQUIN COUNTY <br /> Unit Supervisors <br /> c, .n ?� Donna K. Heran,R.E.H.S. Carl Bor man,R.E.H.S. <br /> 0' < Director 304 East Weber Avenue, Third Floor g <br /> AI Olsen,R.E.H.S. Stockton, California 95202-2708 Mike Huggins,R.E.H.S.,R.D.I. <br /> ogManager Douglas W. Wilson, R.E H.S <br /> Program <br /> 9<raBea Laurie CotManR.E.Hs. Telephone: MargaretLagorio.R.E.H.S. <br /> Program Manager Fax: (209) 464-0138 Robert McClellon,R.E.H.S. <br /> Mark Barcellos,R.E.H.S. <br /> CERTIFICATE OF NON-OPERATION <br /> NOTICE: Health and Safety Code Section 17037.5 requires any person ceasing <br /> to operate or maintain employee housing to annually file a <br /> Certification of Non-Operation with the enforcement agency for two <br /> (2) years following the discontinuation. Section 17037.5 is reprinted <br /> on the reverse side of this page. For additional information call the <br /> Department at (916) 445-9471. <br /> Certificate for Calendar Year 2004_ Employee Housing Facility I.D. No. 39- 00004l <br /> Employee Housing Facility Name K*eq' baa+ i 4 :> 3q—q!� <br /> Address C-Or" -,LSLA'kO '-.�>f'0 c&r&-J CA—q S 1 9 <br /> Operator Name&Address Cf�t�rti rp D ) �>o>< 6 46 --ITO G-ercwj CA- QCx <br /> Telephone Number <br /> D�r_-rs UDS <br /> Property Owner Name&Address u� Dr+.F3t o d .Jo *G tcp � rt+ , C^ qd j <br /> ti- <br /> Reason for Discontinued Operation (Check as appropriate) <br /> Property Sold To: on: <br /> Housing Destroyed (Date): <br /> Housing Facility still exists, but will not be occupied by any employees any part of the year. <br /> Facility will only be occupied by_(less than 5)employees during the calendar year. <br /> ✓ Other, or explanations: P_tA t�r> eftZe*Tua— I'S'ybss CLCC'r�—tio O eCxA-P^ <br /> Maximum number of employees who have or will occupy the facility identified above during the calendar <br /> year <br /> Certification: I, �itEz 1r'+-o+ as <br /> (Print Name) (Title) <br /> certify under penalty of perjury that the information provided herein is true and correct to the best <br /> of my knowle ge. <br /> Signature - Date /2/'r�o3 <br /> UEC 2 1 2003 <br /> ENVIRUNME111 HEALlfi <br /> PERMMSERVICES <br />