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BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />Patricia E. Vannuccl, Secy <br />Tommy Joyce <br />Earl Pimentel <br />Fern Supboe <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />HEALTH DIST*T SERVING <br />SA JOAQUIN LOCAL <br />City of Lodi <br />1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br />City of Escalon <br />Stockton, California 95201 City of Manteca <br />209/466-6781 City of Ripon <br />City of Stockton <br />City of Tracy <br />Jopi Khanna. M.D.. M.P.H., District Health Officer San Joaquin County <br />San Joaquin County <br />RE: CALIFORNIA -LICENSED CONTRACTOR QUESTIONNAIRE <br />In order to comply with State and Local Laws relative to contractor licensing and <br />Workman's Compensation Insurance requirements, we are asking that you provide this <br />District with the information requested below. Please answer all of the questions <br />and return the original of this letter in the self-addressed envelope provided. <br />I <br />BUSINESS NAME <br />BUSINESS ADDRESS <br />BUSINESS TELEPHONE NUMBERS (1) <br />OWNER(S) (1) <br />OWNER(S) ADDRESSES (1) <br />OWNER(S) PHONE NOS (1) <br />CA., CONTRACTOR LICENSE NO. <br />LICENSE CLASSIFICATION (A,B,C) <br />CITY <br />Icon L. Valinoti, Director <br />Environmental Health Division <br />(2) <br />ZIP <br />(2) <br />(2) <br />(2) <br />ISSUE DATE EXP. DATE <br />IF "C" INDICATE SPECIALITY NOS. <br />IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/IES. <br />ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES NO <br />IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br />WORKMAN'S COMPENSATION INSURANCE? YES NO <br />IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES _NO_ <br />IF YES, EXPIRATION DATE <br />SIGNATURE <br />TITLE -- -- <br />DATE <br />