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PUB1IC HEALTH SERVICES oPa�,n <br /> � o <br /> SANJOAQUIN COUNTY r c <br /> P: < <br /> JOGI KHANNA M.U.,M.P.H. <br /> Health Officer c .P <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton, California 95201 S FOiN <br /> (209) 468-3400 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor <br /> licensing and Workman' s Compensation Insurance requirements, we are asking <br /> that you provide this District with the information requested below. <br /> Please answer all of the questions and return the original of this letter <br /> to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME LAYNE ENVIRONMENTAL SERVICES, INC. <br /> BUSINESS ADDRESS 9002 S. HARDY CITY TEMPE, AZ ZIP 85284 <br /> BUSINESS TELEPHONE (1) (602) 496-6500 (2) <br /> OWNER 01 NSA OWNER 02 N/A <br /> ADDRESS ADDRESS <br /> PHONE NO. PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. 600469 ISSUE DATE 08114190 EXP DATE 08131192 <br /> LICENSE CLASSIFICATION (A, B, C) C IF "C" INDICATE SPECIALTY NOS. 57 <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING?7Y7 N <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN' S COMPENSATION INSURANCE? YES x NO _ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? Y <br /> IF YES, EXPIRATION DATE <br /> A CERTIFICATE-OF INSURANCE IS IN THE PROCESS OF BEING ISSUED <br /> SIGNATURE -c_ C'—,-�(. C <br /> TITLE District r 'ager <br /> DATE March 29, 1991 <br /> A Division of S.m Joaquin Courcy Health Cure Services ' <br />