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yh. BOARD OF TRUSTEES SA16OAQUIN LOCAL HEALTH DIST* <br /> t; James Culbertson, Pres. SER INN <br /> Patricia E. Vannuccl, SecCI <br /> y. Y <br /> Tommy Joyce 1601 East Hazelton Avenue, P. 0. Boz 2009 San Joaquin County <br /> Earl Plmentel Stockton, Callfornla 95201 City of Escaton <br /> Fern Bugbee City of Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> John 0. Mast, M.O. City of Stockton <br /> William J. Wade �Ity of Tracy <br /> Jogl Khanru, M.O., M.P.M., District Health Officer San Joaquin County <br /> Mary Anna Love 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 /> M 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 , Director <br /> Environmental Health Division <br /> BUSINESS NAME ,; �t�O.t p,v k--„ j <z Gz <br /> BUSINESS ADDRESS IOOu 014Q,pr l CITY S Cc,��Z,,J ZIP 952c,-:,z;- <br /> BUSINESS TELEPHONE NUMBERS <br /> ' (1) 4(oZ — 1491 11 (2) <br /> OWNER.(S) ( 1) l02 t L, WaQj2cr.J (2) ,, <br /> OWNER(S) ADDRESSES (1) (u tOKCiLrc_�� (2) -2G7Q <br /> OWNER(S) PHONE NOS (1) 4-74 - 3 U5 1 (2) 9tp2 - I� YI <br /> CA. , CONTRACTOR LICENSE NO. t� ISSUE DATE EXP. DATE <br /> LI/C�ENSE CLASSIFICATION (A,B,C) A IF "C" INDICATE SPECIALITY NOS. C -� <br /> L.Or1C.i2.G—�. <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 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES / NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES ANO <br /> IF YES, EXPIRATION DATE 12 �J <br /> SIGNATURE _� Q 3 Q , rt: . <br /> TITLE <br /> DATE <br /> EH 05 30 7-86 <br />