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PUBLL HEALTH SERV ICES <br /> SAN JOAQUIN COUNTY <br /> z <br /> J()Q KHANNA MLD., MT-11. 1 <br /> I Ic�lih Olticcr <br /> P.U. flux 2009 (1601 I-Js' Ilizcho(i Avcnuc) Stockton, Cali(ornij 95201 C<a'FC)!'�' <br /> (209) 468-3100 <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 /> Department with the information requested below. Please answcr all of the questions all(I <br /> return the original of tills letter to Public I Iealth Services Environmental f Iealth Division. <br /> �c Ron Valinoti, Director <br /> Environmental Hcalth Division <br /> BUSINESS NAME v } -S� <br /> BUSINESS ADDRESS 10 L-) S �.�r� n ITY it; 1 v(JIQ ZIP <br /> BUSINESS TELEPHONE 3 1 b4-96,_ (2) <br /> Tei f;oc oe <br /> OW ER #1 C4w41-\�jA, ;'��Q ►�1f. WNER #2 <br /> AD ESS 3 1u��aa II tv n�ck DRESS <br /> PHON O. z41 S--'Z!54- o �45b PHONE NO. <br /> CA., CONTRACTOR LICENSE NO. 62 `f 1 ISSUE DATE EXP DATE <br /> LICENSE CLASS Z ON (A, B, C)�•�IF "C' INDICATE SPECIALTY NOS.25 r7 _ <br /> X02 Ala-f <br /> IF "C-61" CLASSIFICATION; INDICATE TYPE/S LIMITED SPECIALTY/IES- <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES V"' NO IF YOU ARE SUBJECT TO WORKIvfAN'S <br /> COMPENSATION LAWS OT CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES/NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS <br /> DEPARTMENT? YES✓ NO_ IF YES, EXPIRA'T'ION DATE <br /> J <br /> USA S+w-t- <br /> J�b< <br /> 'I'CrLE - <br /> DATE <br /> h:II 00 09 <br /> A I)ivisiun u1$.n�u„luin Cunn,r I Ic,l,l,f,rc Sa•rviaci <br />