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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION 4 <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor - Stockton, CA 95202 6-j <br /> 209/468-3420 <br /> CONTRACTOR/CONSULTANT QUESTIONNAIRE FAY: (209) 464-0138 <br /> BUSINESS NAME: DATE.- <br /> ADDRESS: <br /> ATE:ADDRESS: <br /> CITY/STATE/ZIP <br /> PHONE NO ( ) PHONE 2 { ) FAX# I 1 <br /> :OWNER#I INFORMATION: - OWNER# '.INFORNI'A`FION <br /> NAME: NAi1IE: <br /> ADDRESS: ADDRESS: <br /> CITY: CITY: <br /> STATE: ZIP: STATE: ZIP: <br /> FORNUMON. <br /> LICENSE hi� <br /> LICENSE # DATE ISSCiED / EXP ISSUED r <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 1 1 <br /> WAIVER OF WORKER'S COMP Y N <br /> HAZARDOUS WASTE CLEAN UP CERTIFICATION') Y N <br /> CONSULTING'F'iR:yl INF€7RINIATION <br /> SITE MITIGATION CONSULTING FEPM? Y L SAMPLING FIRM ONLY '' Y N <br /> CA REGISTERED OR CERTIFIED GEOLOGIST Y N NUTNMER <br /> CA REGISTERED OR CERTIFIED ENGINEER Y N NUMBER <br /> PRIMARY QUALIFYING INDIVIDUAL: <br /> Division of`;an lo.n3uin bounty Health litre Services <br />