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.1 7c P.M ST:Q--; ZXPL. 7 <br /> PUBL-C HEALTH ICES <br /> "'i <br /> SAINJOAQUIN CC-UN7.' <br /> NNA kD—M.1.11 <br /> Hvith Office- <br /> 0. Box 2009 (L601 East Hazelton Avenue) Jcvd-cuc%, L.Idarnw 952UI <br /> (209) 4"-3400 <br /> Post4t-t:ranc fax transmittal marne 7671 AGO P'9" <br /> L7, <br /> C-4. <br /> ,CA. X/ <br /> 6s,3 --'5-6f7 -J 7; -CL34F <br /> cZ� MONNAIRE <br /> 7-n order to cc=ply with state and Local Laws relative to contractor <br /> licensing and WorkAtan' s Compensation insurance requirements, we are as'Kinc <br /> ghat you provide this District with the information requested below. <br /> i ?lease answer all of the questions and return the original of this le==er <br /> mo Public Health Services Environmental "Healtlh Division. <br /> Ron val., not-4 , Director <br /> Environmental health Division <br /> BUSINESS 414AME WESTE.X-Wes ter,- Strata Exploration <br /> BUSINESS ADDRESS ? .0. Box 1664 CITY w-st 5:--- ZIP 95691 <br /> BUS:HESS TELEPHONE (1) 916-373-1118 (2) 916-373-1343 <br /> OW-4ZIR X! Svlvie Jansen OWNER i2 <br /> it ADDRESS 4203 W. Capital Aloe-west Sac. ADDRESS <br /> 916-372-540S PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. 5152198 ISSUE DATE -1 -1-88 ---xp DATE 72-Qo <br /> Lic=sz CLASSIFICATION (A, 31 C) C IF "Coo INDICATE SPECIALTY NOS. S7 <br /> C-6111 CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IFS <br /> ARE TwE LICENSES =VZ LISTED ABOVE CURRENTLY ACAND IN GOOD STANDING? & N <br /> :7 YOU A-RE SUEZECT TO WO?jcmXN'S COMPENSATION LAWS OF CALIFORNIA, 00 YOU <br /> CARRY WOR-ICIANIS COMPENSATION INSURANCE? YES <br /> !'-AVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? <br /> IF YES, EXPIRATION DATE 2-91 <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> TOTOL P.at <br />