Laserfiche WebLink
PUBLIC HEALTH SERVICES .Y <br /> V C <br /> SAN JOAQu1N ColfN lY r; �,•c-j o <br /> w 4 <br /> � H <br /> Ja;i KHANNA MD.f+f PH <br /> 11"1111 offuu <br /> o r <br /> 1'() flux 2U09 . (1601 F-AM Ii-1zdLun Avcnuc) . Sluckrun,C.itiforaw 95201 <br /> (2Uy) -168 3-i(W <br /> HE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In Order to comply with State and Local Laws relative to contractor_ltcensing and <br /> Wurk"lan's Compensation Insurance requirements, we are asking that you provide tlua <br /> Department with the information requested below. Please answer all of the questions and <br /> ictutn the original of this letter to Public 11calth Services Environmental Health Division <br /> Ron Valtnoti, Director <br /> Lnvtrutimental Health Dtvhion <br /> BUSINESS NAME Environmental, Solutions, Inc. • <br /> BUSINESS ADDRESS 21 Technology Dr. CITY Irvine,CAZIp 92718 <br /> BUSINES'S TELEPHONE (l) 714/727-9336 (2) <br /> )WNER #j_gichard Ellison OWNER #2 Miro Knezevic <br /> ADDRESS 21 Technology Dr. Irvine, ADDRESS 21 Technology Dr. Irvine, CA <br /> H ION E NO. 714/727-9336 CA Pl ION E NO. 714/727-9336 <br /> CA., CONTRACTOR LICENSE NO. 571380 ISSUE DATE 6/21/8F-XP DATE6/30/91 <br /> LICENSE Cl_ASSII:ICATION (A, B, C) A IF "C` INDICATE SPECIALTY NOS <br /> Il' "C-61" CLASSIFICATION, INDICATE TYPES LIMITED SPECIALTY/lFS <br /> ARE TIIE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> !"I'ANDING? YES—X NO IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> CUMPENSATION INSURANCE? YES x NO_ <br /> II' YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS <br /> t )EI'ARTMl3N 1-1 YES— NO-K- IF YES, EXPIRATION DA'I-E <br /> SIGNA'T'URE . <br /> TI I'LL <br /> DM l? <br /> A 11"0610-d S.11 fur 104L8l unIt 11 .141, 1 ji \ " <br />