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+ r <br /> ' BaARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> JamaS Culban3on, Arai. s ERViNG <br /> Patricia E. Vannuccl, Soc'y. Chy of Lodi <br /> Tommy Joycts 1601 East Haxolton Avonuo, P. 0. Box 2009 San Joaquin County <br /> Carl Pluj ntuf <br /> !'urn ou�auu Stockton, Callfornla 05201 clly of Eycaloo <br /> Clty of Manteca <br /> Dunlor L. Ftoroo 200/466-6781 cuy of nfput, <br /> John D. Mayf, M.D. City of Stockton <br /> Wllltam J. WdUa Jopl Khanna, M.D., M.P.11., Dhitrlct Haallh ofilcor City of Tracy <br /> Mary Anna Lova San Joaquin County <br /> Sun 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 , vie 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 envelopr. provided. <br /> Ron L. Valinoti , Director <br /> Environmental health Division <br /> BUSINESS NAME West Hazmat Drilling <br /> BUSINESS ADDRESS 3 Ft, -.al -- CITY Ran Cordova ZIP9�5742_ <br /> BUSINESS TELEPHONE NUMBERS ( 1) (2) <br /> OWNER (S) ( I) Brine Ni P r m e y P _ (2) <br /> OWNER (S) ADDRESS ( 03a5--, <br /> _, State Colleg�2) Anahiem CA 9280 <br /> OONER (S) PHONE NOS ( 1) _ISL} 77.2--9Q68 (2) — <br /> CA. CONTRACTOR LICENSE NO. ISSUE DATE EXP . DATE <br /> LICENSE CLASSIFICATION (A,B,C) IF "C" INDICATE SPECIALITY NOS. C-57 <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITL-D SPECIALITY/ IES . <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES x NO <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> !dORKMAN'S COMPENSATION INSURANCE? YES x NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT"? YES x NO <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE <br /> DATE <br />