Laserfiche WebLink
aOAnD Of.TRUSTEES SAN-'OAQUIN LOCAL HEALTH DISTRIrv� tERVINa <br /> JamsGulbertson, Pres. City WOO <br /> Patricia E. Vannuccl, sec•y. 1601 East Hazelton Avenue. P.O. Box 2009 San Joaquin County <br /> Tommy Joyce City of Escalon <br /> Earl Pimentel Stockton,California 95201 Cltyof Manteca <br /> Fern Butlbes 209/466$781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast. M.D. City of Tracy <br /> William J. Wade Joel Khanna. M.D., M.P.N., District Health Officer SM Joaquin County <br /> Mary Anna Love San Joaquin County <br /> • TS <br /> PA- <br /> , <br /> /5r'-?,\j CE5 <br /> ER, <br /> RE: CALIFORNIA-LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor licensing and <br /> Workman's Compensation Insurance requirements. we are asking that you provide this <br /> District with the information requested below. Please answer all of the questions <br /> and return the original of* this letter in the self-addressed envelope provided. <br /> Ron L. Valinoti , Acting Director, <br /> -------- -- a .1 . rnmonral wealth Division <br /> BUSINESS NAME Stockton SPrvicp Station Folti ^.mant rmmpany, TNr <br /> BUSINESS ADDRESS 808 N . Union CITY Stnrktnn ZIP cis ms <br /> BUSINESS TELEPHONE NUMBERS (1) 2ngi464-8333 (2) <br /> OWNER(S) ( 1) (Z) <br /> s <br /> OWNER(S) ADDRESSES (1) (Z) <br /> OWNER(S) PHONE NOS (1 ) (2) <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATEnn r_.S XP. DATE on record <br /> LICENSE CLASSIFICATION (A,B,C) C IF "C" INDICATE SPECIALITY NOS. r,I <br /> All information is crrently on record with the S 1 Local Health District . <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/ fES. SA <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES ANO_ <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES X NO <br /> IF YES , HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES X NO_ <br /> IF YES , EXPIRATION DATE Currently on record with County Health District . <br />' SIGNATURE <br /> TITLE <br /> DATE <br />