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ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209)468-3420 <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> Please complete all questions and return. This information is required in order to <br /> comply with STATE and LOCAL_ LAWS. <br /> NAME: Law/Crandall, Inc. DBA: <br /> BUSINESS ADDRESS: 200 Citadel Drive CITY: Los Angeles ZIP 90040 <br /> BUSINESS PHONE:( ) 213-889-5300 PHONE #2J ) <br /> OWNER #1 N/A _OWNER #2 <br /> ADDRESS: _ ADDRESS: <br /> PHONE:_( ) PHONE:( <br /> CALIFORNIA CONTRACTOR LICENSE NO. 653414 DATE OF EXPIRATION: 9/94 <br /> LICENSE CLASSIFICATION (A,B,C) A __LIST SPECIALITY# xAZ C-57 <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y x N CERT.# A5287 <br /> CONSULTANT <br /> ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y x N <br /> DO YOU HAVE EMPLOYEES? Yx N <br /> If you answered NO to above, please coMpleto attached waiver and submit with <br /> questionnaire. If YES, please provide Certificate of Insurance and complete <br /> information below. <br /> NAMF AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER; <br /> NAME: AETNA Life & Casualty Co. <br /> ADDRESS: c/o Willis Corroon Corp. of Georgia <br /> Fire Concourse Parkway, Suite 2600 <br /> PHONE: 404-399-5600 AGENT Ms. Ginger Zachary <br /> Evr,lr':�.i(lid 01-01-95 <br /> SIGNATURE: <br /> Purge I4A <br />