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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVfND <br /> James Culbertson, Pres.PatrWCity of Lodi <br /> Tommy E. vnnucd, Selly 1601 East Hazelton Avenue, P. O. Boz 2009 San JaquinCounty <br /> Tommy Joyce City of Escalon <br /> Earl Pimentel Stockton, California 95201 <br /> Fern Bupbee City of Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> John O. Most, M.D. City of Stockton <br /> City of Tracy <br /> William J. Wade Jopl Khanna, M.D.. M.P.M., District Health Office( ` \ San Joaquin County <br /> Mary Anna Love U San Joaquin County <br /> 69 <br /> � 2�gg9 <br /> Civet,,Sitxv G�SZN <br /> • EN QEgM <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 /> TttFV ARE c1)1ZR Et4 T-LV M <br /> FIL.F_ WITH YOUR A&Erlj <br /> SEF *TfAc/fED DowrnuTTS [ton L. Valinoti , Director <br /> Environmental Health Division <br /> BUSINESS NAME All 0_rr t(\In <br /> BUSINESS ADDRESS �WgLib N1 . Y 965eVr1IC, f CA ZIP 56� <br /> BUSINESS TELEPHONE NUMBERS 1) /(o- J7I- C1,2a_- <br /> 2 (2) <br /> OWNER(S) ( I ) (2) <br /> OWNER(S) ADDRESSES ( 1) (2) <br /> OWNER(S) PHONE NOS (1) _ (2) <br /> CA. , CONTRACTOR LICENSE NO. C5q- L]3783bL]37$3b ISSUE DATE EXP. DATE _ <br /> LICENSE CLASSIFICATION (A,B,C) 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 NO <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES NO _ _ __ <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES NO _ <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> f�ect 3ao�J? I d) TITLE ---- -- - - -- <br /> DATE <br />