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E .. <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson. Pres <br /> City of Lodi <br /> Patricia E Vannuccl, Sec y 1601 fast Hazelton Avenue, P O Box 2009 San Joaquin County <br /> Tommy Joyce City of Escalon <br /> Earl Pimentel Stockton, Callfornia 95201 City of Manteca <br /> Fern Sugbee 2pg/4fi6-6781 City of Ripon <br /> Daniel L Flores City of Stockton <br /> John 0 Masi. M D City of Tracy <br /> William J Wade Jogl Khanna, M D , M P H , District Health Officer San Joaquin County <br /> Mary Anna Love San Joaquin County <br /> RE. CALIFORNIA-LICENSED 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 that 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. Valinoti , Director <br /> Environmental Health Division <br /> BUSINESS NAME <br /> BUSINESS ADDRESS CITY ZIP <br /> BUSINESS TELEPHONE NUMBERS (1) (2) <br /> OWNER(S) ( 1 ) (2) <br /> OWNER(S) ADDRESSES (1) (2) <br /> OWNER(S) PHONE NOS (1) (2) <br /> CA. , CONTRACTOR LICENSE NO ISSUE DATE EXP DATE <br /> LICENSE CLASSIFICATION (A,B,C) IF "C" INDICATE SPECIALITY NOS. <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/ IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES —NO-- <br /> IF <br /> O__IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN' S COMPENSATION INSURANCE? YES NO <br /> IF YES , HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES ____NO <br /> 1F YES , EXPIRATION DATE <br /> SIGNATURE <br /> TITLE _ <br /> DATE <br />