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0 <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. <br /> City of Lodi <br /> Patricia E. Vannuccf, Secy' 1601 East Hazelton Avenue, P. 0. Box 2009 SanJoaqulnCounty <br /> Tommy Joyce City of Escalon <br /> Earl Plmenlel Stockton, California 95201 City of Manteca <br /> Fern Bupbeo City of Ripon <br /> Daniel L. Floras 209/466-6781 <br /> John D. Mast, M.D. City of StocktonCity of Tracy <br /> William J. Wade Jopl Khanna, M.D., M.P.H., Dlstrlct Health Officer San Joaquin County <br /> Mary Anne Love San Joaquin County <br /> rnr] <br /> Airl P <br /> RE: CALIFORNIA-LICENSED CONTRACTOR QUESTIONNAIRE 71819110111121111213141516 <br /> In order to comply with State and Local Laws relative to contractor licensAg and <br /> Workman's Compensation Insurance requirements , we are asking that you provide this <br /> District with the information requested below,. Please answer all of the.questions <br /> and return the original of this letter in the self-addressed elwelope provided. <br /> Ron L. Valinoti , Director <br /> Environmental Health Division <br /> BUSINESS NAME <br /> BUSINESS ADDRESS Z$ZSr Mf -le CITY S-fpc /G 1, C4, ZIP 95_,�'6S— <br /> BUSINESS TELEPHONE NUMBERS (1)(Z22 c{(p$'g7lZ (2) <br /> OWNER (S) (1) ¢ rle.��e�c4x ��o� �•�,(2) <br /> OWNER (S) ADDRESS (1) ZLZI N • v, (2) <br /> nw Gtek- Cs+4 591s <br /> OWNER (S) PHONE NOS ( 1)Ly151 q3-1 - o c,,-o (2) <br /> CA. CONTRACTOR LICENSE NO. 5 LZZCo'S ISSUE DATE EXP. DATE 30 v <br /> LICENSE CLASSIFICATION (A,B,C) IF "C" INDICATE SPECIALITY NOS. <br /> IF "C-ui" CLASSIFICATION, INDICATE T'(PE/S OF LIMITED SPECIALITY/IES . <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES )� NO <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES f NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES X NO_ <br /> IF YES, EXPIRATION DATE - / - 0 <br /> SIGNATURE <br /> TITLE <br /> DATE /y 8 <br />