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PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY )� c�G <br />r.. <br />JOGI KHANNA M.D., M.P.H. <br />Health Officer <br />P.O. Box 2009. (1601 East Hazelton Avenue) Stockton, California 95201 • c,�'FP <br />(209)468-3400 <br />RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br />In order to comply with State and Local Laws relative to contractor <br />licensing and Workman's Compensation Insurance requirements, we are asking <br />that you provide this District with the information requested below. <br />Please answer all of the questions and return the original of this letter <br />to Public Health Services Environmental Health Division. <br />Ron Valinoti, Director <br />Environmental Health Division <br />BUSINESS NAME AQUA SCIENCE ENGINEERS, INC. <br />BUSINESS ADDRESS P. 0, BOX 535 CITY _SAN R_AMON CA ZIP 94583 <br />BUSINESS TELEPHONE (1) (415) 820-9391 (2 ) <br />OWNER #1 W. F. RUSK <br />ADDRESS 17 CATHY LANE, DANVILLE CA 94526 <br />PHONE NO. (415) 837-4153 <br />OWNER #2 DAVID M. SCHULTZ <br />ADDRESS 251 LUGONIA, NEwpogT BAH CA <br />PHONE NO. (714) 631-2313 <br />CA. , CONTRACTOR LICENISE NO. 487000 ISSUE DATE 2-13-86 EXP DATE2-28-92 <br />LICENSE CLASSIFICATION (A, B, C) A/C57/HAZIF "C" INDICATE SPECIALTY NOS. <br />IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br />ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? Y N <br />IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br />CARRY WORKMAN'S COMPENSATION INSURANCE? YES X NO <br />IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT".)6 N <br />IF YES, EXPIRATION DATE 8-15-90 <br />SIGNATURE Jvi1� /�2t W.F. RUSK <br />TITLE PRESIDENT <br />DATE 6-7-90 <br />A Division of Sin Joaquin County Health Care Services 0 <br />