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12-23-1995 09: 12RM FROM TO 19160070002 P.06 <br /> CONTP rOR CONSULTAi3 QUEST!ONNA? E <br /> PUBLIC HEA—ITT' SERVICES <br /> SN JOLQUIN COUNTY <br /> ENVIROIZi,iENTP.L iiEnLTH DIVISION <br /> i P .O. BOX 308 STOCKTOIN CA 45201 -0388 <br /> t <br /> OWNER INFORIMATION <br /> BUSINESS NAME <br /> ADDRESS : �jSF1� F�15� 1��. 4f <br /> I <br /> CITY/STATE/QIP : C/Q L7Tj -G <br /> PHONE NO PHONE PHONE NO 2 ( ) FAX NO (q'C } -�3f�T -6S-Z- <br /> OWNER 41 INFORMATION � � ����,� 3111NE1 42 INFORMATION <br /> NAME: <br /> ADDRESS : IDF,FSS <br /> I <br /> CITY: ` k'TTY . <br /> STATE : ZIP : STATE : ZIP: <br /> LICENSE TO`; <br /> CA CONTRACTOR LICENSE DATA =SSUED / / EXP DATE <br /> I <br /> LICENSE CLASS 1 LICcI�'SE LICENSE CLASS 3 <br /> nC" SPECIALITY 4 ' S <br /> TYPES OF LIMITED SPECI.-".LTY (IES) <br /> I <br /> LICENSE IN GOOD STANDING? Y N WORKERS COMP INSURANCE Y N <br /> WORKERS COMP INSURANCE CERTIF IC�TION 01.7 FILE ytITH E . H . D . ? Y N <br /> ?XPIRATION DATE <br /> HAZARDOUS I-I_STE CL_PN U? C7.. :C_._ _ . :+ - _ N <br /> CONSULTING F- I:R INF OFJ-IATION <br /> SITE MITIGATION CONSULTING FIRM? r SAMPLING FIRM ONLY? Y <br /> CA REGISTERED O CERTIFIED EOLOGIST/ENGIr:EE ? N ' <br /> PRIMARY QUALIFYING INDIVIDU::L <br /> GEO/ENGINEERING REG/CERT Ni�id � � <br />