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PURLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ) ' <br /> JOGI KHANNA M.D.,M.P.H. uX <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton,California 95201 • F. <br /> �%CTTTT <br /> 1.' <br /> • �,PZ n M�1 <br /> • ENVRCNMENTA!HGF !TH <br /> PERMIT ISERVIC'` <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 / �/� �4-In I. <br /> �� <br /> BUSINESS ADDRESS CITY ,�,�„ �, ,�.t,�(�,r, ZIP --/S6 70 <br /> BUSINESS TELEPHONE (1) 6-K F -63k-)-pPS (2) <br /> OWNER 11 Jif d f L� L. &Vle y6 6;mi-gvl OWNER #2 iJC t� v fL_ <br /> ADDRESS / y �c le5 Lc=t ;{ - to-- CAik RaAADDRESS t-„jCJF o� J Vick 44 <br /> PHONE NO. t” -YOOPHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. -- 716S"`/97 ISSUE DATEEXP DATE 1�/I-- <br /> LICENSE CLASSIFICATION (A, B,� IF "C" INDICATE SPECIALTY NOS. ? <br /> IF 11C-6111 CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING?(,X) <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN'S COMPENSATION INSURANCE? YES A NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? N <br /> IF YES, EXPIRATION DATES%N�% <br /> SIGNATURE <br /> r � <br /> TITLE ,5<7' 1, <br /> DATE k6jGyy <br /> A Division of Sin Joaquin Cnnnty Health Care Services <br />