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-T JUN 25 '90 00:48 r P <br /> .3/6 <br /> PUBLIC HEALTH SERVICE � <br /> SAN JOAQUJN COUNTY <br /> f OGI KHANNA RD,,M.P.H. <br /> h"Ith Qftscet + <br /> P.O.BQX 2009,+ (1602 East Hazalton AvtAuf,, . Swt�cun, California 95202 <br /> (201)468.3420 <br /> RE; C.ALIFOMIA LICENSED CONTRACTOR QUEST1QNXXXRE <br /> In order to comply with State and LoCal IAMB ralative to contractor <br /> licensing and 'Workman's Compensation Insuranoe requirements, we are asking <br /> that you provide this Distriot with the infOrmatiOn requested beIOW• <br /> Please answar all of the questions and roturn the original of th' s lattal: <br /> to Public Health Services Environmental Health Division- <br /> Ron valianoti, Director <br /> Environmental Health Division <br /> 'BUSINESS NAM <br /> BUSYNESS ADDRWS � 2� 2n, �r,UM�.'t7FLt.l>i �YTY •S.�1G�RItil4Erlr!) .CA,: r �5�i 5 `-� <br /> SUSINESB 'TELEi�Ha; E (�.y �.- (2) <br /> OWNER #1 _ <br /> .Tomo nr4llingsuV OWNER' <br /> ADDRESS Salt Lake Cit WBSS ..�.._....,. ... <br /> PHONE HO. Utan PHONE NO. .......� ^r.. <br /> CA. , CONTRACTOR LICENSE NO*584007 ISSUE DATE 1 -8-90 EXP DATE —� <br /> LICENSE CLASSIFICATION (Af $, C) IF "M't INDICATE` SPECIALTY NOv.,�, <br /> • yY�IYW.YMr•� IIi.I�iYlpii.lA/'�.Iw^.FI.I.. I <br /> IF "Cwdl" CLASSIFICATION, INDICATI TYPE/S OF LIMITED SPZCIALTY/IES <br /> ARE THE LICENgES LISTED ABOVE CUMPNTLY ACTIVE AND IN GOOD STANDING? Y x)Axx <br /> IF YOU ARE SViJECT To WORKMA141s COMPENSA LAWS OF CALZrORNIA, DO WfJ <br /> CARRY WORM4 N'S COMPEI+SkTION INSURANCE? YE XX}cX NQ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DZSTRICT'? <br /> IF YES, EXPIRATION DATE <br /> DATE ,F iL n A <br /> A AIVF)10Y1 of Raninigoh G).nty Hc�lth CSfi tueY;cc. <br />