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%"' C-- —­3 <br />PUBL�C HEALTH SElt igs <br />SAN JOAQUIN COUNTY pAYME <br />RECEIVED <br />ENVIRONMENTAL HEALTH DIVIS" 2 1992 <br />445 N.SAN JOAQUIN <br />STOCKTON, CA. 95201 SAN <br />PUB-LIC HU-.0 <br />(209)468-3420 EN`t,RONI�,',EN-iALHEALt�',Ol'u'SiON <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:D B A: T F-AjeeE' Ive, <br />ARCE �L P <br />BUSINESS ADDRESS:-71�O/ F400r#&L CITY: -7—ux-t.L 19 ZIP <br />BUSINESS PHONE:(WO q4TI- 7#710 —PHONE #2 -(Vjo) IPC/- Me Y <br />i <br />OWNER #1 Me -OWNER #2 <br />ADDRESS:_ Q&mg ADDRESS: <br />PHONE:( ) - &�Alvrbc PHONE: ( ) <br />CALIFORNIA CONTRACTOR LICENSE NO. -VT4V 9914 DATE OF EXPIRATION:— <br />LICENSE CLASSIFICATION (A,B,C) CIO C 61/n" IST SPECIALITY# <br />I <br />HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y N& CERT.# <br />ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y4jj3 N <br />. NAME ANDADDRESS OF WORKMAN'S COMPENSATION CARRIE4 <br />A� <br />FWA191 91 *a 1443 <br />PHONE: AGENT <br />POLICY # <br />EXPIRATION DATE: <br />DATE: - // <br />A Nvkioll nl San joarilihi Cnointy I Iralth Care Scrvicrs <br />