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CON-ACTOR/CONSULTANT QUESTION"NnIRE <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 : <br /> ADDRESS : <br /> CITY/STATE/ZIP: <br /> PHONE NO ( ) PHONE NO 2 ( ) FAX NO ( ) <br /> OWNER #1 INFORMATION OWNER #2 INFORMATION <br /> NAME : NAME : <br /> ADDRESS : ADDRESS : <br /> CITY: CITY: <br /> STATE : ZIP : STATE : ZIP : <br /> LICENSE INFORMATION <br /> CA CONTRACTOR LICENSE DATE ISSUED / / EXP DATE <br /> LICENSE CLASS 1 LICENSE CLASS 2 LICENSE CLASS 3 <br /> "C" SPECIALITY #' S <br /> TYPES OF LIMITED SPECIALTY (IES) <br /> LICENSE IN GOOD STANDING? Y N WORKERS COMP INSURANCE Y N <br /> WORKERS COMP INSURANCE CERTIFICATION ON FILE WITH E .H.D. ? Y N <br /> EXPIRATION DATE / /• <br /> HAZARDOUS WASTE CLEAN UP CERTIFICATION? Y N <br /> CONSULTING FIRM INFORMATION <br /> SITE MITIGATION CONSULTING FIRM? Y N SAMPLING FIRM ONLY? Y N <br /> CA REGISTERED OR CERTIFIED GEOLOGIST/ENGINEER? Y N <br /> PRIMARY QUALIFYING INDIVIDUAL: <br /> GEO/ENGINEERING REG/CERT NUMBER: <br />