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-SERVING <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT City of Lodi- <br /> ` James Culbertson, Pres. San Joaquin County <br /> Patricia E. vannuccl, Secy. 1601 fast Hazelton Avenue, P. 0. BOX 2009 City of Escalon <br /> City of Manteca <br /> Anthonette van Spronsen Stockton, California 95201 City of Ripon <br /> Earl Plmentel <br /> Fern Bugbee 209/466-6781 City it Stockton <br /> Daniel L. Flores City of Tracy <br /> John l Mast, M.D. San Joaquin County <br /> William J. Wade Jogi Khanna, M.D., M.P.H., District Health officer SanJoaquinCounty <br /> Mary Anna Love <br /> Gentlemen <br /> In order to comply with State and locaeSents�rweaareecontractor <br /> tlicensing <br /> askingthatyouprovide <br /> and Workman' s Compensation insurance req Tr <br /> this District with the information requested below. Return this questionnaire. <br /> Please answer all questions: <br /> e I an 13 11 Ila 11 Fill , erector <br /> Environmental Health Division <br /> CALIFORNIA-LICENSED CONTRACTOR (QUESTIONNAIRE <br /> Business Name ji <br /> ffW" Zi / <br /> ,5��Q y p <br /> Business Address ,3 ,� �� � <br /> Business Telephone Number/s f f <br /> Owners of Business (2) ,1 ES L <br /> KSS O <br /> 1 t y !N Q U i Sf S� g !�[b <br /> Owners Address/es (1 )j�40 ST . Z U� City��,v <br /> s-y� <br /> Owner/s Telephone Number/s /` ~�'3 cense xpiration a e / <br /> License issue Date — - G <br /> License Classification , <br /> If "C" Classification, indica e specia i y num er s <br /> e s of limited speciaTltY 1es- <br /> If "C-61 " Classification, indicate typ I s 1, noPJ &7ud1V* <br /> F .v rra K.S <br /> Are the licenses listed above currently active and in good standing? <br /> es No— <br /> If <br /> ngon <br /> you are subject to Workmen' s Compensation Laws of California, Y <br /> Workmen 's Compensation Insurance? Yes �o his District? Yes ,f <br /> No + <br /> � <br /> If yes, have you filed Certificate of Insurance with t <br /> If yes, expiration date Signature <br /> Title Ir_ <br /> 1 Date <br /> EH 00 30 1 /82 ReJv. f <br />