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f SERVING <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT City Of Lod! <br /> Jitmea Culoartaon,Prea. San Joaquin CCU nay <br /> P i4a E.vannucal,Secy- 1601 East Hazelton Avenue,P.0.Box 2009 CI1y of Eacalon <br /> City of ManlV4 <br /> Ta ;Joyce Stockton,Catlfocnla95201 city of Ripon <br /> Earl Pllnantel Cily o!S1oCk10A <br /> Furn eupnea 2091466-6781 C[1yof Tracy <br /> Daniel L.Florae <br /> San Joaquin County <br /> John 0,Meal,141.0- <br /> William J,Wads Jopl Khanna, M.1)., M.P.H., 01afrlcf Health Officer San Joaquin County <br /> Mary Anna Love <br /> RE: CALIFORNIA-LICENSED CONTRACTOR QUESTIONNAIRE ' e to contractpr licensing and <br /> In order to comply with State and Local Laws relat v that you provide this <br /> Workman's Compensation Insurance requirements, we are asking all of <br /> PI <br /> District with the information requestedetter inethelow•selfeaddressedase renvelope provided. <br /> and return the original of this <br /> Ron L. Valinoti , Director <br /> Environmental Health Division <br /> Gardner & Dunne, Inc- <br /> ,.�'iSINESS NAME Staa <br /> 1 <br /> Ventura ZIP 93001 <br /> is"USINESS'ADDRESS 121 N First St —b53-5556TY {Z} .f <br /> BUSINESS TELEPHONE NUMBERS (1}SOS Dunne, Jahn Po+sell, Martin Feeney <br /> OWNER (S) (1) 1vaar Staal, David Gatdner, Timothy <br /> OWNER (S) ADDRESS {1) {Z) <br /> 04NERR (S) PHONE NOS (1) EXP. DATE <br /> CA. CONTRACTOR LICENSE NO.not applicable ISSUE DATE J <br /> LICENSE CLASSIFICATION (A,B,C) IF "C" INDICATE SPECIALITY NOS. <br /> IF "C-61" CLASSIFICATION, INDICATE TYP£IS OF LIMITED SPECIALITY/IES- <br /> ARE THE LICENSES LISTED ABOVE CURRE'rITLY ACTIVE AND ISN GOODCALIOR+AAD160?�tO�EyARRYNO� <br /> IF YOU ARE SUBJECT TO WORM'S COMPENSATION LAtaS <br /> 0 <br /> tJORKMAN'S COMPENSATION INSURANCE? YES Xx��—WITH <br /> TJiIS'OI ICT YES _ NO XXX <br /> IF YES, HAVE YOU FILED A CERT1`7,ICATE OF INSURA 1 W ' / <br /> -- --- --- ---- ---IF-YES, EXPIRATION--- .Lby David A. Gardner --- —---- -- <br /> SIGNATUR - , <br /> TITLE v ce President <br /> !,. DATE f <br /> u, <br />