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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbartaon, Pres City of Lodi <br /> Patricia E Vannuccl, Secy 1601 East Hazelton Avenue, P. d Box 2009 San Joaquin County <br /> Tommy JoycQ City of Escalon <br /> Earl Plmentel Stockton, Calffornla 95201 City of Manteca <br /> Fern 209/468-&781 city of Ripon <br /> Daniel <br /> L t Flores City of Stockton <br /> John 4 Mast, M D City of Tracy <br /> William J Wade Jotil Khanna, M D . M P M . Dialrict 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 /> Ron L. Vallnotri , 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 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 BATE �T <br /> SIGNATURE <br /> TITLE <br /> DATE _ <br /> f� , <br />