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"JVIIIONMENTAL HEALTH DIViS4,4 <br />445 N.SAN JOAQUIN <br />STOCKTON, CA. 95201 <br />(209)468-3420 <br />Please complete all questions and return. This Information is required In order to <br />comply with STATE and LOCAL LAWS. <br />NAME:i�LL EnJi/I2O/l�hi[�7CJT7at.��C 08A: 5A7vt� <br />BUSINESS AOORESS: 2&LI I CQO>ti 44+vVo.4j 1247 CITY: SArJ aA1'-(OAJ 21P 9 '573 <br />BUSINESS I PIIONE:00= 3 -;?7_-/ PHONE#2 00)30/322,c <br />OWNER 91 GuU coy OWNER 12 <br />ADE)RESS2(o%l/(jecL.)6obuyoA) f2ol-D ADORESS:z�,v/ L/ZDwffl-nJYO.v40 <br />PHONE: <br />ONE: (571T 322--! <br />CALIFORNIA CONTRACTOR LICENSE NO. (, 54/9/ 9 DATE OF EXPIRATION:434gq <br />LICENSE CLASSIFICATION (A,$,C)_,A LIST SPECIALITY# RA-& <br />HAZARDOUS WASTE CLEAN-UP CERTIRCATION7 Y -2r N_ CERT.# (5_4/c/12 <br />CONSULTANTf}2 C ��i/!�//ZOiyMN7yTxK IN/ <br />ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y-4 N_, <br />DO YOU HAVE EMPLOYEES? Y_;4 N_ <br />If you answered NO to above, please complete attached waiver and submit with <br />questionnaire. if YES, please provide Carsiffiga a of Insurance and complete <br />informn;lorr below. <br />NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER; <br />ox y 209 0--7 < <br />PHONE:(ti—IDS 5�3-3oonAGENT N/ff <br />EXPIRATION DATE: 10123 <br />SIGNATURE:�/��} <br />a4414z <br />,c�c 1V �(crc r�� aeti i Fo 1 (4 0 9123I5,� <br />