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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Jamas Culbertson, Pres. City of Lodi <br /> Patricia E. Vannuccl, Secy. 1601 East Hazelton Avenue, P. 0. Box 2009 San Joaquin County <br /> Tommy Joyce City of Escalon <br /> Earl Plmentel Stockton, California 95201 City of Manteca <br /> Fern Bugbee 209/466-6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John 0. Most. M.O. City of Tracy <br /> William J. Wada Jogl Khanna, M.D., M.P.M., Dlatrlct Health Officer San Joaquin County <br /> Mary Anna Love 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 /> Kon L . Val inoti , Uirec.tor <br /> Environmental Health Division <br /> BUSINESS NAME <br /> P <br /> BUSINESS ADDRESS ZgZs e, Aj1r+Lc CITY 1_-4acV4tx, ZIP <br /> BUSINESS TELEPHONE NUMBERS ( 1 ) ) q&5-- $l t'tr _(2) <br /> OWNER(S) ( 1 ) _`�u I>`-��w�L� CV (hc. (2) _ - - ---- ---- <br /> OWNER(S) ADDRESSES ( 1) 2lZl IN ( :Xw;4 (2) <br /> OWNER(S) PHONE NOS ( 1) r{I - -13q- pZ(.o o (2) <br /> CA. , CONTRACTOR LICENSE NO. S1 Zz_�g ISSUE DATE EXP. DATE <br /> LICENSE CLASSIFICATION (A,B ,C) _e_ IF "C" INDICATE SPECIALITY NOS. <br /> IF "C-61 " CLASSIFICATION , INDICATE TYPE/S OF l. fr�iTED �Plt. lP [ IYi11 `� . <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACT IV[ AND IN GOOD ')TANDINr;? YES NO <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAIIF0kNIA, 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 />