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BOARD of TRusTEI=.s SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> -James Culbertson, Pres. <br /> Patricia E. Vannuccl, Secy City of Lodi, <br /> Tommy Joyce 1601 East Hazelton Avenue, P.O. Box 2009 San Joaquin County <br /> City of Escaion <br /> Earl Plmentel Stockton, California 95201 <br /> Fan Supbee City of Manteca <br /> Daniel L. Floras 209/466-6781 City of Ripon <br /> John 0. Most, M.O. City of Stockton <br /> - <br /> William J. Wade - Jog! Khanna. of Tracy <br /> Snna, M.O., M.P.H., District Health Officer an Joaquin County <br /> Mary Anna love San Joaquin County <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_rinformation 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 CITY ZIP <br /> BUSINESS TELEPHONE NUMBERS ( 1 ) (2) <br /> OWNER(S) ( 1 ) (2) <br /> OWNER(S) ADDRESSES ( 1) {2) <br /> OWNER(S) PHONE NOS ( 1) (2) <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATE __ EXP. DATE <br /> LICENSE CLASSIFICATION (A,B,C) 1F "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 <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 /> TITLE --- <br /> DATE <br />