Laserfiche WebLink
11 '22:'_.? 1?•1(7 a 916 662 1592 WA)T•r�-,' DEV. CORP. 01 <br /> ' Iw -LI UK, TURL �iCK p _ <br /> PUBLIC HEALTH SERVICES <br /> SANJOAQUIN COUNTY <br /> JOGI K14ANNA)db,M.P.H, � <br /> P 0. Sox 2009 . <br /> Neahh Officer <br /> •', <br /> (1GOI Last Ha I(On Avrnur) • 5�u�klun,C411fornju 9520f ai <br /> (209) 4611-,1400 o <br /> RE: CALIFORNIA LICVNSED CONTRACTOR VUESTIOUNAIRE <br /> In order to comply with State ,and Local Laws slat <br /> licensing and Workman'sive to contractor <br /> that you Provide this Distr,ictswith ntl�eofnfor�arl�uixam�nts <br /> Please answer all of the questions and return thaoon r0quested balow.we are askirig <br /> to Public Health services Environmental Health Divisi <br /> �'iQ�na1 0�' this letter <br /> ori, <br /> Ron Val'noti, Director <br /> Envfronm*nta,� Health Division <br /> BUSINESS NAME <br /> BUSINESS <br /> ADDRESS p V) . . <br /> BUSINESS TELEPHONE 1 �: CITY ���'� <br /> OWNER r' <br /> ADDRESS "''` _ OWNER f2 <br /> -� C`x',11 <br /> PHONE no. y .. ADDRESS <br /> PHONE NO. <br /> CA. , CONTxACT01t LrCgNSE <br /> LICENSE CLASSIFICATION (A, 8 ISSUE PATE EXP DATE C. <br /> rr, " 11 I"NOIGATE SPECIALTY Nos,-.,�. <br /> IF nC-6111 CLASSIFICATIbN <br /> INDICATETYPES OF LIMITED SPECIALTY/I13 <br /> ARE THE LICENSES LISTED ABoVE CURRENTLY ACTIVE A <br /> IF YOU ARE SUBJECT TO WORKKANoS COMPENSATION LAWA OF ND IN OOD STANDING'�yjj <br /> CARRY WORKKAN'g COMPENSATION INSURANCE? YES CALYFoRNIA, Do YOU <br /> IF YES, NO <br /> HAVE YOU FILED A CERTI ICATS OF YNSUXANCE <br /> XF YES, EXPIRATION DATE �n c C) WITH THIS DISTRICT+? ��) N <br /> �j <br /> SIGNATURZ _- �• <br /> DATE �� �. <br />