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CONTRACTOR/CONSULTANT QUESTIONNAIRE' <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: F$G�( �In4Jifbv�1^ e0„�S�fuCF�`r/✓c <br />ADDRESS: 1(2'q(D <br />CITY/STATE/ZIP: 40",erl gSLkp <br />PHONE NO (log ):(07,4�PHONE NO 2 ( ) FAX NO (Wq )347 ..(..)S& <br />OWNER #1 INFORMATION <br />OWNER #2 INFORMATION <br />NAME: ��S G�� <br />NAME: <br />ADDRESS: 'L3-3& G6{b(, <br />ADDRESS: <br />CITY: L OL <br />CITY: <br />STATE: (,1} ZIP: a s <br />STATE: ZIP: <br />LICENSE INFORMATION <br />CA CONTRACTOR LICENSE 1e,Q3 Q(pS DATE ISSUED 2 / J / %L�EXP DATE <br />LICENSE CLASS 1 LICENSE CLASS 2 LICENSE CLASS 3 <br />"C" SPECIALITY #'S <br />TYPES OF LIMITED SPECIALTY(IES) <br />LICENSE IN GOOD STANDING? �Y N WORKERS COMP INSURANCE Y <br />N <br />WORKERS COMP INSURANCE CERTIFICATION ON FILE WITH E.H.D.? Y <br />EXPIRATION DATE <br />HAZARDOUS WASTE CLEAN UP CERTIFICATION? N <br />CONSULTING FIRM INFORMATION <br />SITE MITIGATION CONSULTING FIRM? Y N SAMPLING FIRM ONLY? Y <br />N <br />CA REGISTERED OR CERTIFIED GEOLOGIST/ENGINEER? Y N <br />PRIMARY QUALIFYING INDIVIDUAL: <br />GEO/ENGINEERING REG/CERT NUMBER: <br />