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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGi KHANNA M-D.,M.P.I I. { <br /> linith Ufficcr c•..,. :... <br /> N� <br /> P.U. Ilex 2009 • (1601 fast Itatrlton Avenue) •'StucLtues.Cali[nrnia 95201 <br /> (2W) 4611-3400 <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 /> Department with the information requester! below. Please answer all of the questions and <br /> return the original of this letter to Public: Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME oil Euuioment Service . div . of Keith A . Tallia . Inc :_ <br /> BUSINESS ADDRESS P .10 . Box 950 CITYSan Andreas ZIP 95249 <br /> BUSINESS TELEPHONE (1)209-754-1808 (2) <br /> OWNER #1 Keith A . Tallia-Pres . OWNER #2 <br /> ADDRESS same ADDRESS <br /> PHONE NO. 209-754-1808 PHONE NO. <br /> CA., CONTRACTOR LICENSE NO.3 2 3 417 ISSUE DATE EXP DATE 5/31/95 <br /> LICENSE CLASSIFICATION (A, B, C) A IF "C' INDICATE SPECIALTY NOS.— <br /> C-21 , C-57 <br /> IF "C-61" CLASSIFICATION, INDICATE TYPES LIMITED SPECIALTY/IES <br /> C61__Q40 . C61-02.1 - - -_ <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES-2L NO IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES_,,,,NO_ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WPI'I'I THIS <br /> DEPARTMENT? YES X NO_ IF YES, EXPIRA'T'ION DATE 3/5/94 <br /> SIGNATURI.: ith al is <br /> i'I rl-E President <br /> DATI- 11/2/93 <br /> 1III 00 09 <br /> A ni�isi� �5+"�w.�uin Cuum�1(a�lb('err 5rrrwKs <br />