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CONTRACTOR/CONSULTANT QUESTIONNA• <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388 STOCKTON CA 95201-0388 <br />OWNER INFORMATION <br />BUSINESS NAME: <br />ADDRESS: <br />CITY/STATE/ZIP: <br />PHONE NO ( ) PHONE NO 2 ( <br />) FAX NO ( ) <br />OWNER #1 INFORMATION <br />OWNER #2 INFORMATION <br />NAME: <br />NAME: <br />ADDRESS: <br />ADDRESS: <br />CITY: <br />CITY: <br />STATE: ZIP: <br />STATE: ZIP: <br />LICENSE INFORMATION <br />CA CONTRACTOR LICENSE DATE ISSUED / / EXP DATE <br />LICENSE CLASS 1 LICENSE CLASS <br />2 LICENSE CLASS <br />3 <br />"C" SPECIALITY #'S <br />TYPES OF LIMITED SPECIALTY(IES) <br />LICENSE IN GOOD STANDING? Y N <br />WORKERS COMP INSURANCE <br />Y N <br />WORKERS COMP INSURANCE CERTIFICATION ON <br />FILE WITH E.H.D.? Y <br />N <br />EXPIRATION DATE <br />HAZARDOUS WASTE CLEAN UP CERTIFICATION? <br />Y N <br />CONSULTING FIRM <br />INFORMATION <br />SITE MITIGATION CONSULTING FIRM? Y N SAMPLING FIRM ONLY? <br />Y N <br />CA REGISTERED OR CERTIFIED GEOLOGIST/ENGINEER? Y N <br />PRIMARY QUALIFYING INDIVIDUAL: <br />GEO/ENGINEERING REG/CERT NUMBER: <br />