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QUlly... N�° { SA NPJ 0 A QU I N Environmental Health Department —COUNTY — Greatness aP Greatness grows here. CERTIFICATE OF NON-OPERATION CALENDAR YEAR 2026 Any person ceasing to operate or maintain employee housing is required to annually file a Certificate of Non-Operation with the enforcement agency for two 2 ears following the discontinuation. EMPLOYEE HOUSING FACILITY NAME: ADDRESS: PHONE: OPERATOR NAME: ADDRESS: PHONE: PROPERTY OWNER NAME: ADDRESS: PHONE: REASON FOR NON-OPERATION (CHECK AS APPROPRIATE): ❑ Property Sold -TO: Date Sold: ❑ Housing Destroyed — Date: ❑ Housing Still Exists: ❑ Will not be occupied by any employees any part of this calendar year. ❑ Will only be occupied by less than 5 employees this calendar year. Maximum number of Employees who have or will occupy the housing during this calendar year: ❑ Other: AUTHORITY: California Health and Safety Code, Section 17037.5(a)-Any person who ceases to operate or maintain employee housing which is subject to the permit requirement pursuant to this part shall be required to annually complete and submit a Certificate of Non-Operation to the enforcement Agency. The Certificate of Non-Operation shall be submitted for two (2)years following the discontinuation of the use of any area on the property as employee housing. The Certificate of Non-Operation shall attest under penalty of perjury that the employee housing has been destroyed, or is no longer owned or operated, or has not been and shall not be occupied by five or more employees during the calendar year. California Health and Safety Code, Section 17037.5(b)-The Certificate on Non-Operation shall include the owner's name and address, the operator's name and address,the employee housing name and location,the maximum number of employees who have occupied or shall occupy the employee housing during the calendar year, and any other information considered relevant by the enforcement agency. The Certificate of Non-Operation shall be completed and submitted to the enforcement agency no later than 30 calendar days after the enforcement agency rovides the form to the owner oroperator. CERTIFICATION: 1, as (Print Name) (Title) certify under penalty of perjury that the information provided herein is true and correct to the best of my knowledge. SIGNATURE DATE EHD USE ONLY EMPLOYEE HOUSING 39- PROGRAM PROGRAM ID: RECORD ID: PR ELEMENT: EHD 27-06 10/26/09 EMP HSG CE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com