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ENVIRONMENTAL NEALTFI DIVISION <br /> 445 N.SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209)468-3420 <br /> GA_L_I�U�NI�LIGED�QNT�igCiiISTIONNAIRE <br /> Please complete all questions and return. This information is required In order to <br /> comply with STATE and LOCAL LAWS. <br /> NAME: DBA: <br /> BUSINESS ADDRESS: CITY: ZIP <br /> RUSINESS Pi IONS:-(_)_ __._ __Pi LONE #2A 1 <br /> OWNFR #1 OWNER #2 <br /> ADDRESS: ADDRESS: <br /> PI-IONE:A_) PHONE: I <br /> CALIFORNIA CONTRACTOR LICENSE NO. DATE OF EXPIRATION:_ <br /> LICENSE CLASSIFICATION (A,B,C) LIST SPECIALITY# <br /> IIAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y_ N_ CERT.# <br /> CONSULTANT <br /> ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y_ N <br /> DO YOU HAVE EMPLOYEES? Y_ N_ <br /> If you answered NO to above, please complete attached wafv_er 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 /> PI IONS: AGENT <br /> EXPIRATION DATE: <br /> SIGNATURE: <br /> Post-ItT"brand fax transmittal memo 7671 #of pages ► <br /> ToFrom, <br /> - /K�✓E <br /> Co <br /> Dept. Phone# 1- /6 9-17-' <br /> ZJ 3 3 <br /> Fax#(oa) q31-3766 Fax# ,/L/ <br />