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i [1CT i3-1" � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 IN-SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> 120934.68-3420 <br /> L)FORNIA LICENSED GONIBACTOI QUESTIOM81RE <br /> Pimse conVAeW at# questions and return_ This Infa m man is required in order to <br /> comply with STATE and LOCAL LAWS. <br /> NAME:'J_e-AC&j Aldi .��Go�E3A: <br /> 13USINESS ADDRESS: _CI Y:!gam 9:f rp Q�o1 <br /> BUSINESS PHONE:..-}AtCJ• q Cp -ag"- j PHONE # <br /> OWNER #1 !-tom - OWNER 02 <br /> ADDRESS: ADDRESS• <br /> PHONE;_1 aIra• I PH01YE- -TtI.5•449 i <br /> CALIFORNIA CONTRACTOR LICENSE NO 4p;0��'pATE OF EXPIRATIaN:-42171 Iq 5P <br /> LICENSE CLASSIFICATION (A,%C}_ Ci LIST SPECIALITY#--til_ <br /> HAZARDOUS WASTE CLEAN-UP CEKTIFICATION7 Y__N CERT.# <br /> CONSULTANT _ <br /> ARE LICENSES LISTED CURRENTLYA TIVE AND IN GOOD STANDING? YIN <br /> DO YOU 14AVE EMPLOYEES7 YN._ <br /> If you answered NO to above, please complete attached waiver and submit with <br /> ques#icmneire_ If YES, fstuase provide Certilloats tit Ir50ar;23 nd complete <br /> information below. <br /> NAME AND ADDRESS OF WORKMAN`S COMPENSATION CARRIM <br /> NAME: p _ <br /> ADDRESS: .---�— <br /> PHONE: `T7' � AGEAfT MDS�hAc <br /> EXPIRATICAN CIA'L._:tA_L'W <br /> SIGNATURE: J AA <br /> ICCe Ir-cGl��� D � Sun��CE 3IE Send <br /> o Cb u 14 n� U,,(�k 5 e~A-rE- CO VEP–, Pages 144 <br /> TOTAL P.02 <br /> J <br />