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PUBLt HEALTH SERVICES <br /> ,O UIry <br /> SAN JOAQUIN COUNTY '°'�• <br /> r. <br /> fOGI KHANNA M.D.,M.P.H. ` <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton,California 95201 c't/�0,0i <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 NAMEsf�[�a �M �LORAT'�� <br /> BUSINESS ADDRESS <br /> BUSINESS TELEPHONE (1)t. MY2Tf ST. CITY TOfJ ZIP <br /> �r //.- (Z) <br /> OWNER #1 <br /> ADDRESS OWNER #2 <br /> PHONE NO. ADDRESS <br /> PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO.,j_/ ISSUE DATE <br /> LICENSE CLASSIFICATION (A, B, C n tt EXP DATE <br /> IF C INDICATE SPECIALTY NOS. <br /> IF 11C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING. 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 CERTIFI ATE OF INSURANCE WITH THIS DISTRICT?cD N <br /> IF YES, EXPIRATION DATE �� <br /> SIGNATURE � <br /> TITLE <br /> DATE <br /> A Division(-Mn)nequin Courcy HeAch Cur Servic(+ <br />