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BOARD OF TRUSTEES SO JOAQUIN LOCAL HEALTH DAICT SERVING <br /> James Culbertson. Pres. <br /> City of <br /> Patricia E. Vannuccl, sx•y. 1601 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> di <br /> Tommy Joyce y <br /> Earl Pimentel Stockton, California 95201 city of Escalon <br /> Fern Bupbee City of Manteca <br /> Daniel L. Flores 209/466$781 City of Ripon <br /> John D. Mast, M.D. City of Stockton <br /> William J. Wade Jopl Khanna, M.D., M.P.H., District Health Officer City of Tracy <br /> Mary Anna Love San Joaquin County <br /> San Joaquin County <br /> REE ' <br /> MAY 15 1992 <br /> ENVIROiNP,4r P'Z f 1. <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 , Director <br /> Environmental Health Division <br /> BUSINESS NAME <br /> BUSINESS ADDRESS�6. A, e/�� CITY 4�;_ ZIP <br /> BUSINESS TELEPHONE NUMBERS (1) `/D8--'J3G- VVJ f (2) <br /> OWNER(S) (1) /,,,c__ (2) <br /> OWNER(S) ADDRESSES (1) (2) <br /> OWNER(S) PHONE NOS (1) (2) <br /> CA. , CONTRACTOR LICENSE NO. 9s/aoL ISSUE DATE /90 EXP. DATE <br /> LICENSE CLASSIFICATION (A,B,C) IF "C" INDICATE SPECIALITY NOS. <br /> e- 3G4 C -y cy.2 cacr- -/G <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 _ X NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES _NO_ <br /> IF YES, EXPIRATION DATE Wc= eco y,)AG -0 C� <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> EH 05 30 7_66 <br />