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F <br /> J9•i+. ip?] I" l_ =?0 ESTEP.l, ;TP4T4 EXPL. P•+31 <br /> PUBLIC HEALTH SE_,R__ V_ 10E,S ,iw4 <br /> 1 <br /> ;awl KHArtNn KC)..M.71!. lia r <br /> Hellch Officer �'- <br /> P.O.Box 2009 • (1601 East Hawimn Avcnue) 51uu:tun Cilliillrma`152Ji <br /> (2&))458-3.160 <br /> "^ Pa-stAl bran(]fax Iransmiltal memo 7671 E�To <br /> • f <br /> i <br /> r,(oir� flu a ca u.}eS7`tr)C <br /> o.vl• vna�f �j 7.,�� 1/l� <br /> r.SOS-loS3-,5-1W7' 'j!/A-J 7_� -0,1'fef <br /> R CNNAIRE <br /> in order to ::omply with State and Local Laws relative to contractor <br /> j licensing and Workmaw s compensation Insurance requirements, we are asking <br /> r 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 /> -i Ron valinoti,• Director <br /> -; Environmental Health Division <br /> ti BUSINESS NAME WESTER-Western S tralla Exolor a;-,ion <br /> BUSINESS ADDRESS P.Q. Box 1664 CITY wea nr_c- ZIP 95691 <br /> J BUSINESS 'TELEPHONE (1) 916-373-!118 (2) 916-373-1343 <br /> j - OIA-HER 01 Svlvie Jansen _ OWNER if <br /> j ADDRESS 4203 W. CaDitaal. Ave-nest Sac- ADDRESS <br /> 6 <br /> i; <br /> PHONE No. 916-372-5405 - -- PHONE fta. <br /> j <br /> s4 `j CA. CONTRACTOR LICENSE 110. 552198 ISSUE DATE 12--88 EXP DATE 12-an <br /> LICENSE CLASSIFICATION (A, Be C) C IF INC" INDICATE SPECIALTY NOS. 37 <br /> nC-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED A80VE CURRENTLY ACTIVE AND IN GOOD STANDING? Y N <br /> 1g YOU .ARE SUBJECT To WORTO'.A.NIS COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN'IS COMPENSATION INSURANCE? YES X NO <br /> j: IF Y .Sr HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? (i1 N <br /> 1 �. _ �- — ----.EE-X.ES,--EXPIF;'ATIOLi--D?►TE----2--.9.1------ - ------- ------------------- --- <br /> � 5XGNATURE . <br /> j <br /> € i TITLE <br /> r DATE <br /> - .-, Aniriv6wnit,njoz�uinOwn•T &. A. - <br /> .TOTAL P.O1 <br /> i <br /> } --. - - <br /> } <br /> T <br />