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®QARO OFTRUSTEFES <br />James Culbertson, Pru. <br />Patricia E. Yannuccl, Secy. <br />Pommy Joyce <br />Earl Plmentsl <br />Fern Suabae <br />Daniel L. Flom$ <br />John D. Mast. M.D. <br />William J. Wade <br />Mary Anna Lora <br />s <br />MME <br />i . 0 0bHEALTH #RICT <br />1601 E&3t HazeltOn Avonue, P. 0. BOX 2009 <br />95201 <br />09 <br />Jopi Khanna, M.O.. M.P.H., District Health QtftW <br />SERVINO <br />City of Lodi <br />Ban Joaquin County <br />City 0t Eacalon <br />city of Mantaos <br />city Qf Ripon <br />City of Stockton <br />City of Tracy <br />San Joaquin county <br />San Joaquin county <br />RE: CALIFORNIA -LICENSED CONTRACTOR QUESTIONNAIRE <br />In order to comply with State and Local Laws relative o contningc�torliyoupensing andis <br />Workman's Compensation Insurance requireme <br />District with the information requested below. <br />Please answer all of the questions <br />and return the original of this letter in the self-addressed envelope provided. <br />Ron L. Valinoti , DirectOr <br />r' <br />Environmental Health Division <br />BUSINESS NAME L"" CITY `�'� �" _ _ZIP <br />BUSINESS ADDRESS - <br />BUSINESS TELEPHONE NUMBERS (1) (2i <br />2 <br />Co�..rraA (S) (I) Gr �J/9 -- (� � z7 <br />OWNtR(S) ADDRESSES (1)tion so. LIiJ1 0,0 <br />PHONE NQS (1�grx��9 Z ��- <br />2 mos S 3.5.—'7 0.0 <br />(S) ® ' <br />UEDATE EXP. DATE <br />_ <br />CA., CONTRACTOR LICENSE NO. %F ISSaCN INDICATE SPECIALITY NOS. <br />LICENSE CLASSIFICATION (A+B+C) I <br />" TION. INDICATE T <br />IF C-61 CLASSIFICATION, YPE/S OF LIMITED SPECIALITY/IES. <br />_ <br />ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDINGT Yt' "V, -- <br />TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. DO YOU CARRY <br />IF YOU ARE SUBJECTNO <br />WORKMAN'S COMPENSATION INSURANCE? YES D�-NO_ <br />IF YES, HAVE <br />YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES <br />IF YES, EXPIRATION DATE _ <br />SIGNATURE _ <br />T I TLE <br />DATE <br />