Notice: Health and Safety Code Section 17037.5 requires any person ceasing to operate or maintain a labor camp to annually file a Certification of Non-Compliance with the enforcement agency for two years following the discontinuation. Section 17037.5 is reprinted on the reverse side. For additional information call the Department at (209) 525-6700.

Certificate for Calendar Year

Labor Camp Name

Address

Operator Name

Address

Telephone Number

Property Owner Name

Address

Reason for Discontinued Operation (Check as appropriate)

Property Sold

Housing Destroyed

Camp no longer operated

Camp will not be occupied by 5 or more employees during calendar year.

Other, or explanations

Maximum number of employees who have or will occupy the facility identified above during the calendar year

Certification: I 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

House Non-Op Cert.html