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PUBLIC HEALTH SERVILzS �{ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O Box 2009, Stockton, CA 95201 <br /> 445 N. San Joaquin, Stockton <br /> (209)468-3420 <br /> CERTIFICATION OF NON-OPERATION <br /> : .... ...................................................................................................................... <br /> ..................................................................................................... <br /> 98 NOTICE: Health and Safety Code Section 170375 requires any person ceasing to operate <br /> •'sc: or maintain employee housing to annually file a Certification of Non-Operation with the <br /> enforcement agency for two years following the discontinuation. Section 170375 is reprinted <br /> on the reverse side of this page. For additional information call the Department at <br /> (916) 445-9471. <br /> :........::::::::.:................................................................................................................. <br /> ................................................................................................................ <br /> ......:::.......::......................................................................................... <br /> ....................... <br /> Certificate for Calendar Year /L/ Employee Housing Facility LD. No. .3 7 - D) <br /> Employee Housing Facility Name ✓ + n rIA-s r y <br /> Address on w.a` L/ l irz c n n T� lei r cl S L-t k CA 9:5.20 <br /> Operator Name d' r �n .r vr5 <br /> Address f n 4oc G / <br /> Telephone No. i X17 9) yy'- 1�J 9 7 C1 <br /> Property Owner Name NJ fca w tq yX A S / — <br /> Address 4 S 7 r4f 1) c � In 1R/oi> 5�e / ` n ! c �;e ��i c4 )y,5 y <br /> R=-.-= for Discontinued Operation (Check as appropriate) <br /> ❑ Property Sold To: Oa: <br /> ❑ Horsing Destroyed (Date): PA'M <br /> ❑ Housing Facility sell �dstsbut will not be occupied by any employers any Part of year <br /> S FacilitywHl only be occupied by�_(lets than 5) employes ung the calendar year <br /> ❑ Other, or ctplanations <br /> Masimum number of employees who have or wiII occupy the facility identified above during <br /> the calendar year <br /> cid I. r►1 , k CG� f\ b1 // as z <br /> MRWHAMP <br /> certify under penalty of pexjwy that the information provided herein is true and correct to the best <br /> of ray lSignatured „ ��� <br /> Signature /�/ <br />