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N LOCAL HEALTH DISTMCT
<br /> SERVING
<br /> BOARD OF TRUSTEES SAN JOAQUI City of Lodi
<br /> James Culbertson, Pres. San Joaquin County
<br /> Patricia E. Vannucci, Secy. 1601 East Hazelton Avenue, P. 0. Box 2009 City of Escalon
<br /> Anthonatte van Spronsen City of Manteca
<br /> Earl Plmentei Stockton, California 95201 City of Ripon
<br /> Fern Bugbee 209/4.66-6781 City of Stockton
<br /> Daniel L. Flores t4G� �q z() City of Tracy
<br /> John D. Mast, M.D.
<br /> William J. Wade Jogl Khanna, M.D., M.P.N., District Health officer San Joaquin County
<br /> San Joaquin County
<br /> Mary Anna Lowe
<br /> Gentlemen:
<br /> In order to comply with State and local laws relative to contractor licensing
<br /> and Workman' s Compensation insurance requirements , we are asking that you provide
<br /> this District with the information requested below. Return this questionnaire.
<br /> Please answer all questions:
<br /> e an erector
<br /> Environmental Health Division
<br /> CALIFORNIA-LICENSED CONTRACTOR {QUESTIONNAIRE
<br /> Business Name n� Zi
<br /> Business Address Q(j) 0 .',������ --City `T'dLAa-1 P.
<br /> Business Telephone Number/s ,aq (egg —IQgD )q E1
<br /> Owner/s of Business (1 )
<br /> Owner/s Address/es (1 ) City
<br /> Zip . —
<br /> Owner/s Telephone Number/s 9
<br /> License Issue Date Licensexpi�ration a e
<br /> License Classification ,
<br /> If "C" Classification, indica e specia i y num er s
<br /> If "C-fl " Classification, indicate type/s of limited spec allty ies.
<br /> Are the licenses listed above currently active and in good standing? Yes)< tyo
<br /> If you are subject to Workmen' s Compensation Laws of California, do you carry
<br /> Workmen 's Compensation Insurance? Yes_X_No
<br /> If yes, have you filed Certificate of Insurance with this District? Yes ' No
<br /> If yes, expiration date it?_, - `�
<br /> Signature
<br /> Title D
<br /> Date
<br /> EH 00 30 1 /82 ReIV.
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