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PUBLik-", HEALTH SERv'ICJ��) <br /> SAN JOAQUIN COUNTY PAYMEN <br /> r <br /> RECEIVED <br /> ENVIRONMENTAL HEALTH DIVIS" 12 1992 ` r <br /> 445 N.SAN JOAQUIN <br /> STOCKTON, <br /> CA. 95201 PUE'�1C h%��►r"� <br /> (209)468-3420 ENVd ROMAENiALHE.kJr-' 01'J1510N <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> Please complete all questions and return. This information is required in order to <br /> comply with STATE and LOCAL LAWS. <br /> NAME: t !mE�}R _E DBA: I L �t A R CE <br /> BUSINESS ADDRESS:_7'/0/ 00r#1,.L 64-V0- CITY: / u_7iLjV S jQ ZIP 9/0z/.2 <br /> BUSINESS PHONE:(r1) 95/- 77/0 PHONE #2 (fit) 9Si- 7740 <br /> OWNER #1 S4me OWNER #2 <br /> ADDRESS: CAME ADDRESS: <br /> PHONE:_( ) ���,, 6 PHONE:_( ) <br /> CALIFORNIA CONTRACTOR LICENSE NO. VT41996 DATE OF EXPIRATION: <br /> LICENSE CLASSIFICATION (A,B,C) CIO I LIST SPECIALITY# <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y_ NQ CERT.# <br /> ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? YC3 N <br /> NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER: <br /> NAME: <br /> ADDRESS: <br /> PHONE: AGENT <br /> POLICY # <br /> EXPIRATION DATE: <br /> SIGNATURE: TITLE: <br /> DATE: // /c-)'9 Z�a <br /> A 1);%-kinn of San Inarinin(.nnmy I lrilrh(irr Srrvi(" �j <br />