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BOARD OF TRUSTEES <br />James Culbertson, Pres. <br />Patricia E. Vannucci, Secy. <br />Tommy Joyce <br />Earl Plmentel <br />Fern Bugbee <br />Daniel L. Flores <br />John D. Mast, M.D. <br />William J. Wade <br />Mary Anna Love <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 East HazeIton Avenue, P. 0. Box 2009 <br />Stockton, Callfornla 95201 <br />209/466-6781 <br />Jogl Khanna, M.D., M.P.H., District Health Officer <br />SERVING <br />City of Lodi <br />San Joaquin County <br />City of Escalon <br />City of Manteca <br />City of 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 to contractor licensing and <br />Workman's Compensation Insurance requirements, we are asking that you provide this <br />District with the information requested below. 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 />Environmental Health Division <br />BUSINESS NAME <br />BUSINESS ADDRESS <br /> <br />CITY ZIP <br /> <br />BUSINESS TELEPHONE NUMBERS (1) (2) <br />OWNER(S) (I) (2) <br />OWNER(S) ADDRESSES (I) . (2) <br />OWNER(S) PHONE NOS (1) (2) <br />CA., CONTRACTOR LICENSE NO. ISSUE DATE EXP. DATE <br />LICENSE CLASSIFICATION (A,B,C) IF "C" INDICATE SPECIALITY NOS. <br />IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/IES. <br />ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES NO <br />IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br />WORKMAN'S COMPENSATION INSURANCE? YES NO <br />IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES NO <br />IF YES, EXPIRATION DATE <br />SIGNATURE <br />TITLE <br />DATE <br />ru nr ln