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12-23-1996 03:16PM FROM BIIJD USID TO 914153293621 P.02 <br /> I• <br /> lI <br /> i <br /> I ENVIRONMENTAL HEALTH DIViSiO�J <br /> i. 445 N.SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209)468-3420 <br /> 1:. _CALIFOR�IA LICENUEL2 CONTRACTOH. EIONNAIRE <br /> IIf <br /> P e Be complete all qu'Sstiohs and return. This information is required In order to <br /> c ply with STATE ad LOCAL LAWS. <br /> N E: Pitcher Drillling Co DBA: <br /> B ` INESS ADDRESS,,k0 sox 5067 CITY: <br /> Palo Alto Zip 94303 <br /> INESS PHONE:- (415) 328-8910 PHONE #2 4 1 <br /> 00 4EIR k1 Richard OWNER #2Mabel Cordes <br /> A RESB: P.0.Box 367 _ADDRESS: .0. Box 503(17 <br /> P NE: (415)15) 310 PHONE:_(415 <br /> C RNIA CONTRA6TOR LICENSE NO. 263085 DATE OF EXPIRATION:9//30/97 <br /> L NSE CLASSIFICA1jlON (A,B,C) C LIST PECIALITYA 57 . <br /> H ARDOUS WASTE LEAN-UP CERTIFICATION? Y X N I CERT.# <br /> CSULTANT <br /> A R LICENSES LISTED CURRENTLY ACTIVE AND IN GO Oq STANDING? YX N_ <br /> O YOU HAVE EMPLOYEES?. Yx N` <br /> If u answered NO to above, please Complete attached 'waiver and submit with <br /> q .d tionnaire. If YEP, please provide Certi a and complete <br /> Ink oration below. <br /> III <br /> l NjA E AND ADDRESSIOF WORKMAN'S COMPENSATION CARRIER; <br /> ; i i <br /> Nj E: Republic inaemnity Company f AmeriCa <br /> AIRESS: 100 Pine IST. , Suite 1100 . San Fran Ci 5cn ,Ca 94111 <br /> ! + , 'P�i NE:(4.15) 981-32b0 AGENTAon Services, Cheryl Abboot <br /> C� IRATION DAVE: 11--1- 7 <br /> 5i ATURE: � <br /> I <br /> PageI4., <br />