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t <br /> 5OA*O OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Petrlcla E. Vonnuccl, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Tommy Joyce <br /> Earl Plmentel City of Eecalon <br /> Fern BugbeStockton, Caliorna City of Manteca <br /> Daniel L. Flores 209/466-6781 Cit of Ripon <br /> John D. Mast, M.D. City of Stockton <br /> City of Tracy <br /> William J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anne Love San Joaquin County <br /> MAY 15 �V <br /> eNVI 198) <br /> Ff RM T�fRV/�CTy <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 /> Environmental Health Division <br /> BUSINESS NAME Irvin Asphalt Construction <br /> BUSINESS ADDRESS p_n_ Rn„ ti15F CITY Modesto, Ca. ZIP 95355 <br /> BUSINESS TELEPHONE NUMBERS (1) 524-8500 (2) <br /> OWNER(S) (1) Jerry Irvin (2) <br /> OWNER(S) ADDRESSES (1) 1650 Culpepper (2) Modesto, cA. 95351 <br /> OWNER(S) PHONE NOS (1) (209)524-8500 (2) <br /> CA. , CONTRACTOR LICENSE NO. 449751 ISSUE DATE EXP. DATE <br /> LICENSE CLASSIFICATION (A,B,C) A IF "C" INDICATE SPECIALITY NOS. <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/IES. <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES X NO <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES Yes NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES X NO_ <br /> IF YES, EXPIRATION DATE <br /> r <br /> SIG NAT <br /> TITLE ' er <br /> DATE May 1V,1987 <br /> Gu na in <br />