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CONTRACTOR/CONSULTANT QUESTIONNAIRE <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388STOCKTON CA 95201-0388 <br /> -- OWNER INFORMATION <br /> BUSINESS NAME: <br /> Richard o. Bywater <br /> DRESS: P.O. BOX 31600 <br /> Stockton, Ca. 95213 <br /> CITY/STATE/ZIP- <br /> PHONE NO (209) 942-3131 PHONE NO 2 ( ) FAX NO ( 200 941-4439 <br /> OWNER #1 INFORMATION OWNER #2 INFORMATION <br /> NAME: <br /> DRESS: ADDRESS: <br /> CITY: CITY- <br /> STATE: ZIP: STATE: ZIP: <br /> LICENSE INFORMATION <br /> CA CONTRACTOR LICENSE DATE ISSUED / / EXP DATE 3, /31/ 00 <br /> LICENSE CLASS 1 Class 1 LICENSE CLASS 2 LICENSE CLASS 3 <br /> "C" SPECIALITY I'S <br /> PES OF LIMITED SPECIALTY(IES) <br /> LICENSE IN GOOD STANDING? Y es N WORKERS COMP INSURANCE Yes N <br /> R16R.S COMP INSURANCE CERTIFICATION ON FILE WITH E.H.D. ? Yes N <br /> EXPIRATION DATE I / 1 /•99 <br /> HAZARDOUS WASTE CLEAN UP CERTIFICATION? Y NO <br /> CONSULTING FIRM INFORMATION <br /> SITE MITIGATION CONSULTING FIRM? Y N SAMPLING FIRM ONLY? Y N <br /> CA REGISTERED OR CERTIFIED GEOLOGIST/WiGINEER? Y N <br /> PRIMARY QUALIFYING INDIVIDUAL: - <br /> GEO/ENGINEERING REG/CERT NUMBER: <br /> [0 39dd W08d 10:£I 66. 0 ddW <br />