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r <br /> PU %=of swo <br /> BLIC HEALTH <br /> SERVICES �QU 1k <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer : <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) Stuckton, Cdifornia 95201 ";i;j6" <br /> (209) 468-3400 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor <br /> licensing and Workman's Compensation Insurance requirements, we are asking <br /> that you provide this District with the information requested below. <br /> Please answer all of the questions and return the original of this letter <br /> to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME e e-�1 -S r i ib rn <br /> BUSINESS ADDRESS �_� 0 Cl2i'Y lk�. ZIP i S 47 <br /> BUSINESS TELEPHONE (1) 23 <br /> OWNER #1 /y' UNE�OL,p� OWNER #2 Cfm Ll /4W <br /> ADDRESS -L. r ADDRESS <br /> PHONE NO. - 1 ✓ PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. (, j ISSUE DATE EXP DATE / -30-17- <br /> LICENSE CLASSIFICATION (A, B, C) IF "C" INDICATE SPECIALTY NOS. <br /> IF "C-6111 CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? N <br /> IF YOU ARE SUBJECT TO WORKMAN ' S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN'S COMPENSATION INSURANCE? YES K NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? Y <br /> IF YES, EXPIRATION DATEZ-3 1_.r <br /> &t r -V1' 50� �--�? <br /> SIGNATURE ,Aa ¢ <br /> TITLE <br /> :LE42 eX.6 <br /> DATE <br /> A Division of%n f itaquin Gamy Hcahh Care Scrviecs <br />