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PUgVC HEALTH S1 <br /> VIES <br /> SAN JOAQUIN COUNTY <br /> JOGI KH <br /> ANNA M.U.,M.P.H. <br /> r' :s <br /> :< <br /> Health OFficer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Sttxkttm,California 95201 <br /> (209)468-3400 ,,E� <br /> �n <br /> U <br /> • PR 0 5 1990 <br /> ENR E HEALTH <br /> RE: <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE SIM <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 i►,+d �Ie,r e <br /> BUSINESS ADDRESS ffo a .$klsla 2gy �s.A Zip 9fG9/ <br /> BUSINESS TELEPHONE (1) 9/6 3 71--y 7az (2) <br /> OWNER 11 � �,_.. . /hc OWNER 12 <br /> ADDRESS ADDRESS <br /> PHONE N0. PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATE EXP DATE Z <br /> LICENSE CLASSIFICATION (A, B, C) -.0 IF "C" INDICATE SPECIALTY N S. S-7 . <br /> 6 � <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> >n*//, . <br /> ARE THE LICENSE LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? Y N <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN'S COMPENSATION INSURANCE? YES )�_ NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT?�N <br /> IF YES, EXPIRATION DATES j /qgo <br /> SIGNATUR <br /> TITLE -� <br /> DATE }� <br /> A Division of San finquin County Health Care Servims <br />