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PUUt* HEALTHStR110ES <br /> a�,N <br /> SAN JOAQUIN COUNTY aP <br /> JOGI KHANNA M.D.,M.P.H. '4 <br /> Heal(h Officer < <br /> P.O. Box 2009 . (1601 Last Hazelton Avenue) Stockton, California 95201 �4ciFo�e <br /> (209) 4168-3400 _ <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 /> Department with the information requested below. Please answer all of the questions and <br /> return The original of this letter to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME (,0(Cj 2 V) (A sCLQ rS <br /> BUSINESS ADDRESS23(o 3 8cxk�e oard av _ <br /> BUSINESS TELEPHONE (1)X41 S-� �(�cA �I � �� IP_ ��U S y <br /> OWNER #1b-e c - , , N���, (,e�tWNER #2 — <br /> ADDRESS l�0 2 ADDRESS <br /> PHONE NO. !E" (6-Vk0,A ( A C-,(I PHONE NO. <br /> Lfls-C);o-cow(* <br /> CA., CONTRACTOR LICENSE NO. (u 3 ISSUE DATEEXP DATE ,2 31 <br /> �(i <br /> LICENSE CLASSIFICATION (A, B, C) IF "C" INDICATE SPECIALTY Nos._ <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S LIMITED SPECIALTY/IF.S <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES4 NO IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES�NO_ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS <br /> DEPARTMENT? YESZ NO_ IF YES, EXPIRATION DATE 10 k o _ , 0 <br /> RECEIVED SIGNATURE ( c v (eve <br /> JUN 15 1990 TITLE 11 o5ii ,;°W c�-- <br /> 1 � ��� , <br /> ENVIRONMENTAL HEALTH DATE_ (US <br /> PERMIT/SERVICES <br /> Eli 00 09 <br /> A Division of Sanfoiquin County lir.ilih Care Services <br />