Laserfiche WebLink
CON­ <br />_?-DOOR/CONSULTANT QUESTION24`( <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: _ Glf EVR-o U• S, A <br />✓275 7�/aLY �L✓®. <br />ADDRESS: <br />CITY/STATE/ZIP: <br />PHONE NO () ZI PHONE NO 2 ( ) FAX NO ( <br />) <br />OWNER #1 INFORMATION <br />OWNER #2 INFORMATION <br />p <br />NAME: / r �Ut ulS.Al �rr4kcl� Co. <br />NAME: <br />ADDRESS: Q,J• 0.0y, ��7 <br />ADDRESS: <br />Shfj 4MAN <br />CITY: <br />CITY: <br />STATE: C -k ZIP: g 4 5 S 3 <br />STATE: <br />ZIP: <br />LICENSE INFORMATION <br />CA CONTRACTOR LICENSE ;if 3/l (off �j DATE ISSUED / / EXP <br />DATE <br />(te) C, 4,7 —D// -o <br />LICENSE CLASS 1 LICENSE CLASS 2 LICENSE <br />CLASS 3 <br />"C" SPECIALITY #'S Ems) <br />TYPES OF LIMITED SPECIALTY(IES) <br />LICENSE IN GOOD STANDING? 0 N WORKERS COMP INSURANCE <br />O N <br />N <br />WORKERS COMP INSURANCE CERTIFICATION ON FILE WITH E.H.D.? <br />EXPIRATION DATE <br />HAZARDOUS WASTE CLEAN UP CERTIFICATION? Y N <br />CONSULTING FIRM INFORMATION <br />SITE MITIGATION CONSULTING FIRM? N SAMPLING FIRM <br />ONLY? Y N <br />IZVCH s7'o4(e PeVeLoPEAS <br />CA REGISTERED OR CERTIFIED GEOLOGIST/ENGINEER? o N <br />PRIMARY QUALIFYING INDIVIDUAL: <br />Jai /y1oKR�E' <br />• <br />GEO/ENGINEERING REG/CERT NUMBER: c•�v .��o/�- <br />