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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> James Culbertson, Pres. City of Lodi <br /> Patricia E. Vannucci, Secy. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> Anlhonetle Van Spronsen City of Escalon <br /> Earl Pimentel Stockton, California 95201 City of Manteca <br /> Fern Bugbee 209/466-6781 City of Ripon <br /> Daniel L. Flores City of Stockton <br /> John D. Mast, M.D. City of Tracy <br /> William J. Wade Jog[ 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 ACME CONSTRUCTION COMPANY INC. <br /> Business Address 1565 Cunim ns Drive City Modesto Zip 95351 <br /> Business Telephone Number/s 523-2674 <br /> Owner/s of Business (1j Philip Mastagni-President <br /> (2 <br /> Owner/s Address/es (1 ) same as above City Zip <br /> (2) City Zip <br /> Owner/s Telephone Number/s 523-2674 — <br /> License Issue Date 4-15-57 icensexpiration a e6-30-87 <br /> License Classification B1=167130 " <br /> If "C" Classification, indicate speciality num er s <br /> If "C-61 " Classification, indicate type/s of limited special ies. <br /> Are the licenses listed above currently active and in good standing? Yes XX No_ <br /> If you are subject to Workmen' s Compensation Laws of California, do you carry <br /> Workmen's Compensation Insurance? Yes XXNo_ Note: Requested Certificate on <br /> er <br /> If yes, have you filed Certificate of Insurance with thispDistil25 ct`.a9 Yes_)'!o_ <br /> If yes, expiration date 7-86 <br /> Signature <br /> Title Pro'ect Man er <br /> Date April 25, 1 86 <br /> EH 00 30 1/82 ReN. <br />