Laserfiche WebLink
PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DMSION <br />Karen Furst, M.D., M.P.H., Health Officer, ` <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />UVIN l'KAU'1'UK/Ut)iN N U L I'AiN 1 (1 U EJ'1'lUININAI FtE P'AX: (2U`I) 464-U 132E <br />BUSINESS NAME: DATE: <br />ADDRESS: <br />CITY/STATE/ZIP <br />PHONE NO ( ) PHONE 2 ( ) FAX # ( ) <br />NAME: <br />NAME: <br />ADDRESS: <br />ADDRESS: <br />CITY: <br />CITY: <br />STATE: ZIP: <br />STATE: ZIP: <br />LICENSE # DATE ISSUED / / EXP ISSUED / <br />LICENSE CLASS 1 LICENSE CLASS 2 LICENSE CLASS 3 <br />"C" SPECIALTY # <br />TYPES OF LIMITED SPECIALTY (IES) <br />LICENSE IN GOOD STANDING? Y N WORKER'S COMP Y N <br />WORKER'S COMP CERTIFICATION ON FILE WITH E.H.D. Y N EXP DATE <br />WAIVER OF WORKER'S COMP Y N <br />HAZARDOUS WASTE CLEAN UP CERTIFICATION? Y N <br />SITE MITIGATION CONSULTING FIRM? <br />CA REGISTERED OR CERTIFIED GEOLOGIST Y <br />CA REGISTERED OR CERTIFIED ENGINEER Y <br />PRIMARY QUALIFYING INDIVIDUAL: <br />Y N SAMPLING FIRM ONLY? <br />N NUMBER <br />N NUMBER <br />A Division of San Joaquin County Health Care Services <br />Y N <br />