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BOARD OF-TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRI-CY SERVING <br /> James Culbertson, Pros. City of Lodi <br /> Patricia E. Vannuccl. Secy. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Tommy Joyce City of Escalon <br /> Earl Plmentel Stockton, California 95201 City of Manteca <br /> Fern Bupbee 209/466-8781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Joel Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Love San Joaquin County <br /> \J <br /> G <br /> LNV\V'0 )SEK ESZH <br /> RE: CALIFORNIA-LICENSED CONTRACTOR QUESTIONNAIRE V <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 Sto -k nn SPrvica Station Fnii ^ment rmmpanY, INC <br /> BUSINESS ADDRESS 808 N . Union CITY Stnrktnn ZIP g57n5 <br /> BUSINESS TELEPHONE NUMBERS (1) 209/464-8333 (2) <br /> OWNER(S) (1 ) (2) <br /> OWNER(S) ADDRESSES (1) (2) <br /> OWNER(S) PHONE NOS ( 1) (2) <br /> CA. , CONTRACTOR LICENSE NO. 10g10S ISSUE DATE nn rarn, SXP. DATE on record <br /> LICENSE CLASSIFICATION (A,B,C) C IF "C" INDICATE SPECIALITY NOS. r1 <br /> All information is crrently on record with the S_7. Local Health District . <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/ IES. SA <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES _X_NO_ <br /> IF YOU ARE SUBJECT TO WORKMAN'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 X NO_ <br /> IF YES , EXPIRATION DATE Currently on record with County Health District - <br /> SIGNATURE <br /> is rict _SIGNATURE <br /> TITLE <br /> DATE <br />