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SOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Janes Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl, Secy. 1601 Eaal Hazelton Avenue, P. O. Box 2009 San JaquinCounty <br /> Tommy Joyce Gly of Escafon <br /> Earl Plmentel Stockton, C:allfornla 95201 City of Manteca <br /> Fern Bupbee 209/4666781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John 0. Mast. M.O. City of Tracy <br /> William J. Wade Jogl Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Low San Joaquin County <br /> RE: CALIFORNIA-LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor licensing and <br /> Workman's Compensation Insurance requirements, we are asking that you provide this <br /> District with the information requested below. Please answer all of the questions <br /> and return the original of' this letter in the self-addressed envelope provided. <br /> Ron L. Valinoti , Acting Director <br /> Environmental Health Division <br /> BUSINESS NAME City of Tracy <br /> BUSINESS ADDRESS 3900 Holly Dr. CITY Tracy ZIP 95376 <br /> BUSINESS TELEPHONE NUMBERS (1) 836-1650 (2) 836-1651 <br /> OWNER(S) (1) City of Tracy (2) <br /> OWNER(S) ADDRESSES (1) 3900 Holly Dr. (2) <br /> OWNER(S) PHONE NOS (1) (2) <br /> CA. , CONTRACTOR LICENSE NO. N/A ISSUE DATE EXP. DATE <br /> LICENSE CLASSIFICATION (A,B,C) IF "C" INDICATE SPECIALITY NOS. <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/IES. <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES _NO_ <br /> IF'YOU ARE SUBJECT TO WORn4AN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES x NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES _NO_ <br /> IF YES, EXPIRATION DATE <br /> SIGNATUR <br /> TITLE <br /> DATE <br />