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r a�3rL4r1996 14= 1-3, FROM wI -TERM SSRATR 5XPL. TO 180"535687 P.01 <br /> PUBLIC. HEALTH SERVIit , <br /> tea, ? <br /> SANjOAQtIIN CCUN E'`t' r. <br /> OGI KHANNA MD.,M.F.I is <br /> He lth©fficrr <br /> .I0-Box 2Z34J * (10:k EAlt Hazct(nn Avcnue) ' $40 rt,n,tris"ft�rrsix�15?t�1 s�o- <br /> ('209)468-3400 <br /> Pas#-ftll brand fax.fransmittal memo 7671 n of e�► �,�' <br /> I)@pt=: �1r1 <br /> p <br /> Ril <br /> It1 Qrclex� to c ;mp�x With St$tt and Local: Laws relative. to contractor <br /> lcerts:'ri <br /> g end WOrkoeni s C+ca pensation Insurance requirements, we ars: asking <br /> that tou ptvv do tl xa District with the ,informata.on requested b4Tow. <br /> P1,6448 ans r r all of the queS Ions and return this drg3.ria1~ of this YaCt;Er <br /> to Pu Ii.t. H+�a , h Services En ronmental :iealth Division. <br /> Ron valitl - Director <br /> Environmental Health Division- <br /> BUSINESS <br /> iv si nBUSINESS NAME WESTEx--western Strata Ex2l0X tion <br /> :BUSINESS Abt REaS P-0. Box 1664: CITY _Lgia .p - n _ ZIP 954.9 1 <br /> BUSINESS TELEPHONE (1) 916-3 7 3-1l 18 <br /> {2) 97.6--373-I.343.. . .... <br /> 0"k;A ;II SY.ly e Jensen OWNER 3# <br /> A€ DArss 4207—W:- <br /> Capital Ave-West Sac. ADDRESS <br /> HONE No. 916-372-5405 PHONE NO. <br /> CA , CONTRACTOR LICENSE- no. 552198 ISSUE FATE 12-88 EXP DATE` <br /> LICENSE CLASSIFICATION {A, B, C) IF teC" INDICATE SPECIALTY NOS. 57 <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/`S OF LIMITED SPECIALTY/ItS _ <br /> AAE THE LICENSEs LISTED ABOVE CURRENTLY ACTIVE ANSA IN COAD STANDING? �� N <br /> TF YOU ARE SUBJECT TO WOFJ MAW`S COMPENSATION LAWS OF CALlrORNI.A DO You <br /> CARRY WORIQW'S COMPENSATION INSURANCE? YES X NO <br /> I <br /> YES HAVE Xt7 3 FILED A CERTIFxCATE OF INSURANCE WITH THIS :DISTRICT?;i y� ;fit <br /> :[F XE3; EXPIRA' CN LATE 2--91 <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> A tXvis6a of:fan J.,Muiq 0,wsttrT Mejith Carr fiK'ss. <br />