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r <br />PUBLIC HEALTH SERV' :S <br />_ SAN JOAQUIN COUNTY N --e <br />PAMELA S. VIOLETT, R.E.H.S. <br />Senior Registered Environmental Health Specialist <br />Environmental SRJrI�%� 1 <br />Health Division (445 N. San Joaquin Street) <br />,'09)468-0335 P.O. Boz 2009 <br />FAX (209) 464-0138 Stockton. CA 95201-2009 <br />... <br />ONMENTAL HEALTH DIVISION <br />445 N.SAN JOAQUIN <br />STOCKTON, CA. 95201 <br />(209)468-3420 �0'i p 4 ;993 <br />�E`�ISEDJQ _ONTRAG19ri_Q_V_ETli ORl llti• VIENfA_ HEALTH <br />r=i17/SERVICES <br />Please complete all questions and return. This Information is required In order to <br />comply with STATE and LOCAL LAWS. <br />NAME: rlN6 /UeuNt_�i 1 DBA: /L1 SJ`G T G����C.91 �ZIC _ <br />BUSINESS ADDnES5:5 EL %.^o Iia_ CITY:�G���A7ZIPS-, (2630 <br />BUSINESS PIZONE: LM efScl_l'fo0 PHONE #2 0.4 S32 -4X119 <br />OWNER #1rl{NT <br />ADDRESS: 22 3 5 <br />PHONE:_ tog- yS (/- <br />VNER A <br />DRESS <br />CALIFORNIA CONTRACTOR LICENSE NO.4&j2'97 DATE OF EXPIRATION:— <br />/1%2_17 <br />LICENSE CLASSIFICATION fA,B,C) /r LIST SPECIALITY#C?/—CS7 <br />IIAZAnDOUS WASTE CLEAN-UP CERTIFICATION? Y� N_ CEnT.# <br />CONSULTANT <br />ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y_C N_ <br />DO YOU tIAVE EMPLOYEES? Y_ NSC <br />If you answered NO to above, please complete attached walvqr and submit with <br />questionnaire. If YES, please provide Certificate of Insurance and complete <br />Information below. , <br />NAME AND ADDRESS OF WORKMAN'S <br />NAME: <br />ADDRESS: Z Z W <br />PFIONE: AIaENT, <br />EXPIRATION DATE: <br />SIGNATURE: <br />PSATION CARRIER; <br />a <br />