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Rug. 11 '98 9,30 PRRG/RCI FAX 805-643-91 0 P. 2 <br /> 8-11-1996 9:21 AM FP0 �..I <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQM COUNTY <br /> ENVIRONMENTAL HEALTH DMSION <br /> Koen Furst, M.D.,M.M., Health Officcr r; <br /> 304 East Weber Avenut,Third.Floor•Stockton,CA 95202 •t; ~ <br /> 209145E-3420 <br /> 8 <br /> CONIrRACTOR/CONSULTANT UtSTZQNNAiREpFAX: 209 464-0138 <br /> W S N _ Ka"+ DATE',F5I jf/ `i8 <br /> ADDRESS, 3njC? W, G�ran4 <br /> CITY/STATEIZIF 1 rGcC q!r Y4, <br /> PHONE NO Zc"$t) $SIo 5'79{ PHONE 2( ) FAX 0( ) <br /> NAMK: <br /> +a � <br /> NAME; <br /> ADDRESS: 7 011 ADDRESS: <br /> Crit: �f vvnV iL <br /> CITY: <br /> STATE.ZIP: f'�F� ! 1 Ip S'T'ATE:ZIP: <br /> r.Y ' ♦ ti- w 1 t p. <br /> ��iMf •'W +sn. :�.„• } F .. •���t� `, ',/: w" �Mtl. Farr j �' ! - �rY <br /> PATZ [IED 3 /1 /95 EXP ISSUED 3 / 3! 9 9 <br /> LICENSE CLAS t LICENSE CLASS 2 LICENSE CLASS 3 <br /> "C"SPECIALTY # 5'+4 t_` <br /> TYPES OF LD4"-ED SPECIALTY(IES) <br /> LICENSE IN GOOD STANVING7 (YZ N WORKER'S COMP G) N <br /> WORKER'S COMP CERTIFICATION ON F WITH E_H.D Y ) N EXP DATE <br /> De4We a of w/py"Yc - <br /> WAIVER OF WORKERS COMP Y <br /> UrI1YCrrrf wI Pgfy,Sx <br /> HAZARDOUS WASTE CLEANUP CERTIFICATION 7 /4 Y N <br /> ry .:.�»w..w+.x.. wT *f' .H.. b -: ♦. {T r'. mrH�}`.A. d!ffSM 4 1-,- <br /> TIGATI N NS RM? Y N SAMPLING FIRM ONLY 7 Y N <br /> CA REGISTERED OR CERTIFIED GEOLOGIST Y� N NUMBER Q(jj <br /> CA REGISTERED OR LBILTIFMD F_ G1NEER Y N NUMMER <br /> PRIMARY QUALIFYING 1NDIN TDUAL: <br /> btiF, ?imt 9 606 <br /> S( �t- EFR A} CAL 0a0IU63S <br /> l , <br />