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DOAAD Of TRUSTEFS <br />Jamos Culbartoon, Pres. <br />F*dc a E. Vennuccl, Sac'y. <br />Tommy Joyce <br />Eul Plmontsl <br />Fern Supbea <br />Daniel t„ Florae <br />John O. Mast. M.O. <br />William J. W"o <br />Mary Anna Low <br />SAN JCFAQUIN LOCAL HEALTH DISTRICT".. sEftvlHa <br />City of Lodi <br />1601 East Hazelton Avenue, P. O. Box 2009 S"JoaQuincounty <br />Stockton, California 95201 City of Escalon <br />city of Manton <br />209/466-46781 City of Ripon <br />City of Stockton <br />Joel Khanna, M.D.. M.P.H., District Health officer City of Tracy <br />San Joaquin County <br />San Joaquin County <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 Dlrectot <br />Environmental Health Division <br />BUSINESS NAME <br />BUSINESS ADDRESS (J�/�nJC CITY//��� ZIP <br />BUSINESS TELEPHONE NUMBERS (1)Q/�-Q��-a(�6y (2)/6_ga0 O�'7 <br />OWNER(S) ErfUnacG (2) <br />OWNER(S) ADDRESSES(1) 9/_3a' GA�i(2) <br />OWNER(S) PHONE NOS (1) y��.- qy/_��/� (2) <br />CA., CONTRACTOR LICENSE NO. _ ISSUE DATE /0c EXP. DATE /9946 <br />LICENSE CLASSIFICATION (A.B.C) IF "C" INDICATE SPECIALITY NOS. <br />L'.-.2/ , L-6 / <br />IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/IES. <br />d -/,/-DIG <br />ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES N0 <br />IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, <br />WORKMAN'S COMPENSATION INSURANCE? YES / NO <br />IF YES, HAVE YOU FILED A CERTIFICATE OF, INSURANCE WITH THIS DISTRICT? YES VNO_ <br />IF YES, EXPIRATION DATE <br />SIGNATURE <br />TITLE <br />DATE <br />H 05 30 7 04 <br />DO YOU CARRY <br />