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r <br /> HOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James CultWlson, Pres City of Lodi <br /> Pâ– Irlcla E Vannuccl, sec y 1601 East Hazelton Avenue, P O Box 2009 San Joaquln County <br /> Tommy Joyce City of Escalon <br /> Earl Plmenial Stockton, Callfornla 95201 City of Manteca <br /> Fern 209/466-6781 City of Ripon <br /> L Flores Fl <br /> Daniell L City of Stockton <br /> John D Mast, M O City of Tracy <br /> William J Wade Jopl Khanna, M D , M P H , District Health Officer San Joaquin County <br /> Mary Anna Love San Joaquin County <br /> RE CALIFORNIA-LICENSED CONTRACTOR QUEST1014NAIRE <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 /> [ton 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 /> I <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 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 /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE <br /> DATE - <br />