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ZOARD Of TRUSTEES SAN OAQUIN LOCAL HEALTH 01STR - ��slAvt►ia <br /> JamesCulhartaon, Pros. Cityotlodl <br /> Patricia E. vannuccl, sac•y• 1601 East Hazelton Aventra, P. O. Box 2009 San Joaquln County <br /> yommy Joyas Citrof Eaulon <br /> W,tt Plmantet Stockton, California95201 Clly;ol!Manteca <br /> 1' gvp°~ 209/466 678 t City of AtPon <br /> iisniel L. Fiat" City of Stockton <br /> Joan 0. Mast. M.D. '•CityatTtaey <br /> William J. Wada JoCl Khanna, M.D., M.P.tt., Dla(riCt Health61tlCa San J040111County i <br /> Mary Anna Low San Joaquin county <br /> i <br /> i <br /> t <br /> RE: CALIFORNIA-LICENSEO 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 tl:at 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 /> _ lion L. Valinot:i , Director <br /> Environmental Hezith Division <br /> ` rBUSINESS NAMEoec��ycw� �>GP � I r,C- <br /> BUSINESS ADORESS 7.$25 r�, /Y1u,44 CITY -�zr� ,, ZIP C75-zc <br /> BUSINESS TELEPHONE NUMBERS ( 1 ) 0q) q6 $-712 (2)(Z3) SLC - 2033 <br /> 014NER(S) (1 ) 12) <br /> OWNER(S) ADDRESSES (1 ) <br /> OWNER(S) PHONE NOS ( 1) 9 - Cnla (2) <br /> CA. , CONTRACTOR LICENSE NO. S IZZ(2 g ISSUE DATE ,, v. EXP, DATE (¢ <br /> LICENSE CLASSIFICATION (A,B .C) IF "C" INDICATE SPECIALITY NOS. C - 5-7, <br /> _ <br /> r <br /> IF "C-61" CLASSIFICATION, INDICATE TYPES OF LIMIT-.O SP£C1ALI1r IES . <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND Lv r,000 STANOING? YES NO _ <br /> IF YOU ARE SUBJECT TO WORKMAN' S COMPENSATION LAWS OF CAI. IFORNIA, DO YOU CARRY . <br /> WORKMAN' S COMPENSATION INSURANCE? YES _ _ NO <br /> IF YES , HAVE YOU FILED A CERTIFIC TE OF INSURANCE WITH THIS DISTRICT? YES X ti0 <br /> IF YES , EXPIRATION DATE —_� 89__- ..... <br /> SIGNATURE �N� <br /> TIT:E � / � l�r n$ _ /�G.yt c er^ <br /> DAtE <br />