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ter' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445. N.SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209) 6 -3420 <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> Please complete all questions and return. This information, is required in order to <br /> comply with STATE and LOCAL LAWS. <br /> Advanced <br /> NAME: Environmental Concepts, IncDBA: AEC <br /> BUSINESS ADDRESS: 4400 Ashe Road #206 CITY':. Bakersfield_ ZIP 3 - <br /> BUSINESS PHONE:001 831-1646 PHONE #2 (801- 831-2083 <br /> OWNER #1 Jonathan L. Buck OWNER #2 <br /> ADDRESS: 6308 Glenrock Way, Bakersfield_—ADDRESS: <br /> PHONE: 805 83172083 PHONE:1 <br /> CALIFORNIA CONTRACTOR LICENSE NO. A 720492 DATE OF!EXPIRATION. <br /> LICENSE CLASSIFICATION (A,B,C) A. LIST SPECIALITY# <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y X N_ CERT.# 720492 <br /> CONSULTANT Jonathan Buck <br /> ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y X N <br /> DO YOU HAVE EMPLOYEES? YX N_ <br /> If you answered NO to above, please corriplete attached waiver Wand submit with ' <br /> questionnaire. If . YES, __O!ease provide Certificate of Insurance and complete <br /> information below. <br /> NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER; <br /> NAME: California Compensation Ins. Company <br /> ADDRESS: 504 Redwood Boulevard,_Novato, CA ,.94947 <br /> PHONE: (916)939-1080 .,AGENT Matthew Wallace <br /> EXPIRATION DATE: 1/1/97 <br /> SIGNATURE: <br /> On 12/9/96, �je requested our insurance company,to issue a certificate-of insurance: <br /> to your office. <br /> Page 14A <br />