Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209)468-3420 <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> Please complete all questions and return. This information is required in order to <br /> complylith STATE and LOCAL LAWS. <br /> NAME: ls U)'4T DBA: ZE --1ECA ckEnl c St-lPP+ T <br /> BUSINESS ADDRESS: 113"4 6L11JE AVE • CITY: 0PADMZ ZIP 953W <br /> BUSINESS PHONE: ! N1 395-7 PHONE #20�9)t471 '4 (F4)0 <br /> OWNER #1 TS 7P.uck]1J�S E '909s)xet T `►12UcK1/�](s <br /> ADDRESS: ADDRESS: %() 96C-UO <br /> PHONE: ( ) PHONE: 4 $ lL 11sK1a►4 <br /> CALIFORNIA CONTRACTOR LICENSE NO. 657 3b6 DATE OF EXPIRATION:ll3119 } <br /> LICENSE CLASSIFICATION (A,B,C) A LIST SPECIALITY# <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y4 N_ CERT.# <br /> C0NSULTANT (,0Mu6itAL -Tf,L )) e6 <br /> ARE LICENSES LISTED CURRENTLY ACTIVE, AND IN GOOD STANDING? YX N_ <br /> DO YOU HAVE EMPLOYEES? Y_ NX <br /> If you answered NO to above, please complete attached waiver and submit with <br /> questionnaire. If YES, please provide Certificate of Insurance and complete <br /> information below. <br /> NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER; <br /> NAME: <br /> ADDRESS: <br /> PHONE: AGENT <br /> SIGNATURE: <br /> Page I4A <br />