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11-02-94 02AUM FROM GEA LOS_ANGELES i0 G1LES DALLAS 1 F00S/UUj <br /> 1 <br /> 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 NORTH SAN JOAQUIN <br /> STOCKTON, CALIFORNIA 95201 <br /> (209) 468-3420 <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> ' Please complete all questions and return. This information is required in order to comply with <br /> STATE and LOCAL LAWS. <br /> 1 NAME: Douglas P Dayton DBA: Giles Engineeering Associates Inc <br /> BUSINESS ADDRESS: 4875 E. La Palma Avenue, Suite 607 CITY: Anaheim, CA ZIP. 92807 <br /> 1 BUSINESS PHONE: (714) 779-0052 <br /> � OWNER #1: Terry L. Giles <br /> t ADDRESS: N8 W22350 Johnson road Suite A-1. Waukesha, WI 5' 186 <br /> PHONE: (4141544-0118 <br /> 1 CALIFORNIA CONTRACTOR LICENSE NO. 647935 DATE OF tXPIRATION: June 1996 <br /> ' LICENSE CLASSIFICATION (A,B,C) C LIST SPECIALITY# '57 <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y_ N X !CERT.# <br /> tCONSULANT: <br /> ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOODSTANDING? Y N _ <br /> ' ii DO YOU HAVE EMPLOYEES? Y X N_ <br /> If you answered NO to above, please complete attahced waiver and submit with questionnaire. If <br /> ' YES, please provide Certificate of Insurance and complete information below. <br /> NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER: <br /> ' NAME: Northbrook Property & Casualty Co. <br /> ' ADDRESS: Post Office Box 2000 Brea, CA 92622 <br /> ! <br /> PHONE: 77-280 AGENT. N/A <br /> ' EXPIRATIO DATE: Ma 1 95 <br /> tSIGNAT <br /> 1 <br /> 1 <br />