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BOARD OF TRUSTEES SA"* JOAQUIN LOCAL HEALTH DIST?t•CT SERVING <br /> James Culbertson, Pres.Patricia E. City of Lodl <br /> y <br /> TommJoyce nnuccl, sec t'. 1801 East Hazelton Avenue, P. O. Box 2009 S•n Joaquin County <br /> Y <br /> Earl Plmentel Stockton, California 95201 City nt lon <br /> ea <br /> Fern Bupbee y ofMs <br /> Daniel L. Flores 2097466$781 City of Ripon <br /> John D. Mast, M.D. City of Stockton <br /> fTncy <br /> William J. Wade Jopl Khanna, M.D., M.P.M., District Health Officer Sen JoaquinCity CityCounty <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 /> 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 <br /> BUSINESS ADDRESS J�yh x000 tr�„nCITY _�S/&E�1� ZIp may/ <br /> BUSINESS TELEPHONE NUMBERS (1) (2) <br /> OWNER(S) (1) _ .U�✓/.0 4.c�i ,O- (2) .-- <br /> OWNER(S) ADDRESSES (1) (2)(2) <br /> OWNER(S) PHONE NOS (1) (2) <br /> CA. , CONTRACTOR LICENSE NO. 399' ISSUE DATE EXP. DATE <br /> LICENSE CLASSIFICATION (A,B,C) Z_ /IF "C" INDICATE SPECIALITY NOS. <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 ZNO_ <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAW F CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES t/ NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES NO <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> EH 05 30 7_86 <br /> e <br />