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0 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N. SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209)468-3420 <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> Please complete all questions and return. This information is required in order to <br /> comply with STATE and LOCAL LAWS. <br /> NAME: DBA: <br /> BUSINESS ADDRESS: CITY: ZIP <br /> BUSINESS PHONE:( 1 PHONE #2 ( 1 <br /> OWNER #1 OWNER #2 <br /> ADDRESS: ADDRESS: <br /> PHONE:( ) PHONE:( 1 <br /> CALIFORNIA CONTRACTOR LICENSE NO. DATE OF EXPIRATION: <br /> LICENSE CLASSIFICATION (A,B,C) LIST SPECIALITY# <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y N CERT.# <br /> CONSULTANT <br /> ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y_ N_ <br /> DO YOU HAVE EMPLOYEES? Y_ N_ <br /> If you answered NO to above, please complete attached waiver and submit with <br /> questionnaire. If YES, please provide Certificate of Insurance and complete information <br /> below. <br /> NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER; <br /> NAME: <br /> ADDRESS: <br /> PHONE:( 1 AGENT <br /> EXPIRATION DATE: <br /> SIGNATURE: <br />