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JUL 07 192 09:35 KL' `7ELDER SKTN � . 355 PO <br /> Soo, %Wf <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN CQUNIY ; <br /> JOGI MANNA ht.©.,hu,n. <br /> Iir<<h Uftitrr _ <br /> 3'.0. [lux 2U09 s (1601 East ttaztimll Av;no�:) o $uycktuf:,Califs?pli;i °15201 i " ;• <br /> (20'1) 1168.3400 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to compiy with State and Local Laws relative to contractor licensing and <br /> Workman's ComFensation Insurance requirements, we are: asking; that you provitle this <br /> Department with the information requested below. Pleases answer nll of the: questiolts and <br /> return the originai of this letter to Public Ilealth ServicesEnvironmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME S D '�. <br /> BUSINESS ADDRESS — ( C1'I'Y v ZIF - 57Zc T- <br /> BUSINESS TELEPHONE (I)L?�g 9) (J eT-S1 SZ- (2)_ P.>z t2o-i `�_4q w 06 z f <br /> OWNER #I `Le ��_ OWNER #2 <br /> ADDRESS, t t-It &)- l; . ADDRESS <br /> PHONE NO.,I -L23s �oo PHONE NO. <br /> CA., CONTRACTOR LICENSE NO. S(210 ISSUE DATE a EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) _� IF "C' INDICATE SPECIALTY NOS._ <br /> IF "C•61" CLASSIFICATION, INDICATE TYPEfS LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES—V NO_ IF YOU ARE SUBJECT TO WORWAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES Y-Na_ <br /> IF YES, HAVE YOU FILED A CERTIFICATE 0,F INSURANCE WITH THIS <br /> DEPARTMENT? YES-2� NO„_._ IF YES, EXPIRATION Dxrr,- 9 - 1- R"L <br /> SIGNATURE <br /> TITLE <br /> DATE `I?- <br />