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BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> James Cul Denson, Pres. SERVING <br /> Patricia E. Vennuccl, Secy. City of Lodi <br /> Tommy Joyce 1601 East Hazelton Avenue, P. O. Boz 2009 San Joaquin County <br /> Earl Pimentel Stockton, Call lornla 95201 City of Escelon <br /> Fern BupDee City of Manteca <br /> Daniel L. Flores 209/466-6781 City of Ripon <br /> John D. Mast, M.D. City of Stockton <br /> William J. Wads Jopl Khanna, M.D., M.P.H., District Health officer City of Tracy <br /> Mary Anna Love Sen Joaquin County <br /> San Joaquin County <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 /> District with the information requested below. Please answer all of ,the questions <br /> and return the original of this letter in the self-addressed envelope provided. <br /> Hun L. Valinuti , Director <br /> Environmental Health Division <br /> BUSINESS NAME Spez, .—„ y�(Ar t lwL <br /> BUSINESS ADDRESS _ 2$2sE �ty, le CITY ZIP "LSZor <br /> BUSINESS TELEPHONE NUMBERS ( 1 ) ��g�c((a 1 Z (2) <br /> OWNER(S) ( 1 ) 1� y� <br /> OWNER(S) ADDRESSES (1) ZIZI A). G j� Ldc��nrt.� � ret�cry Q� , <br /> OWNER(S) PHONE NOS (1) ("15-) R341-5"yL (2) <br /> CA. , CONTRACTOR LICENSE NO. -61 Z20 ISSUE DATE _ EXP. DATE91— <br /> LICENSE CLASSIFICATION (A,B,C) C IF "C" INDICATE SPECIALITY NOS. 5- 7 _ <br /> IF "C-G1 " CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/ [ES. <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES 140 <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES J(J NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES 3_�_NO__ <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE TITLEki- <br /> DATE t_ 7 <br /> � --- - <br />