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From,: WEST HAZMAT DRILLING C PHONE No. : 916 636 7276 May- 14 1992 4:50PM PO4 <br /> HEALtH` t r <br /> SAN)0491AN COUNTY � 1 <br /> Pril KI IAfMI'rA 61.0-11 IM <br /> [It lIIIOffiryy t + <br /> �N <br /> �V. lk.h 4UCN • (1601 Ylurl 11.1rAve.ruenck7c,r.. Calllrxnla 7w J.AI <br /> (T(W) 461)•?IUNI <br /> i MAY 14 1992 <br /> �t HEALTHRE; CALIrORNI� LICV-NSED CONtnAC"rOn (]UES'n7NNAIr1F PERMITE <br /> In order to Damply with STATC anti LOCAL LAWS relative to contractor 11ennaing and <br /> Workmen's Con4p6118ntbn tnauranao roqulrolitoMts, wo aro agklnp ihat you provided <br /> this Department with tho inim"Intlon requested below, Please Answer all of the <br /> questions and return tho original of thla 16tior to Public Health Services Environmental <br /> Hoolth tlivlslon.; <br /> I <br /> Rol) Veflnotl, Director <br /> Environtttontal Hoalth Dfvlalon <br /> NAME:�` <br /> r3l1SIN11fiB Al7bflE9S lwC� t CITY <br /> BUSINESS TEL4PHONt3 (1)—j i,(� a .S _'fit . t21___ <br /> 0WNERN1 flD)jrY) k(2r]LL, _OWNER#2 „L0P, 7 ?C. <br /> r <br /> PHONE NO. PH <br /> CENE NO. <br /> .--- <br /> CA. CONTRACTOR LICENSE N0.5„5!jq'7yIS5U>- DATE -zb. l991 -XPDATE� -iii_9 <br /> LICENSE CLA$Stt'ICA1'ION IA,U,CI c. IF"C" INDICATC SPECIALTY NOS,TZ2 <br /> IF "C•61” Ct.AB 'FICPTION, INDICATE TYh1 S LIMIT-Cs SPLCIALT117N A/ <br /> ARE THE ICEN ES LISTED ABOVE CU11INEN1'LY ACTIVE AND IN GOOD STANDIN(31 <br /> YES NO , I IF YOU ARE SUBJE=CT' TO WORKMAN'S COMPENSATION LAWS <br /> OF CALIFORNIA; UO YOU CARRY WORKMAN'S COMPENSATION INSURANCE vviTH <br /> THIS DEPARTMtNTt YES VNO-- IF YES, EXPIRATION DATE <br /> i <br /> I <br /> SIGNATURE t�`• C __ <br /> { TITLE..r...,. C.c <br /> 03/06/02 DATE_ 4Q�/Vlq <br /> I <br /> 1 <br /> A 01004.1f Nn 1^AIDdq t wHIv It,aldi r.au 4K4t," IV <br /> 1 I ' <br /> 1 ' J ".01S ) G 'Irl :'aU ItUJd <br />