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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. Cltyof Lodl <br /> Patricia E. Vannuccl, Secy. 1601 East Hazelton Avenue P. O. Box 2009 San Joaquin County <br /> Anthonette Van Spronsen ,BugbeCity of Escalon <br /> Earl el Stockton, California 95201 City of Manteca <br /> Fern Bug bee Cit of Ripon <br /> Daniel Flores 209/466-6781 City of Stockton <br /> John D.. Mast, M.D. City of Tracy <br /> William J. Wade Jogl Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Love San Joaquin County <br /> Gentlemen: <br /> In order to comply with State and local laws relative to contractor licensing <br /> and Workman's Compensation insurance requirements, we are asking that you provide <br /> this District with the information requested below. Return this questionnaire. <br /> Please answer all questions. <br /> C. Leland a , R.S. , Director <br /> Environmental Health Division <br /> CALIFORNIA-LICENSED CONTRACTOR QUESTIONNAIRE <br /> Business Name Groundwater Technology/Oil Recovery Systems, Inc. <br /> Business Address 5047 Clayton Road City Concord, CA Zip 94521 <br /> Business Telephone Number/s (415) 671-2387 <br /> Owner/s of Business (1 ) Oil Recovery Systems, Inc. <br /> (2) <br /> Owner/s Address/es (1 ) 5047 Clayton Road __ ity Concord, CA Zip 94521 <br /> (2) City Zip <br /> Owner/s Telephone Number/s (415) 671-2387 � — <br /> License Issue Date85 icense xpiration a e Feb. 28, 1987 <br /> License Classification C <br /> If "C" Classification, indica a specta i y num er s x_57 <br /> .t <br /> If "C-61" Classification, indicate type/s of limited specia ty ies. <br /> Are the licenses listed above currently active and in good standing? YesX No_ <br /> If you are subject to Workmen' s Compensation Laws of California, do you carry <br /> Workmen's Compensation Insurance? YesXNo_ <br /> If yes, have you filed Certificate of Insurance with this District? Yes_No X <br /> If yes, expiration date <br /> Signature <br /> Title <br /> Date be <br /> EH 00 30 1/82 Rely. <br /> tii ; <br />