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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> Jacil KI IANNA M.U.,M•P.11. <br /> lealill U((irrt <br /> P0. Hux 21109 • (1601 lust I bulimi Ansior) / Swcklon,California 95201 <br /> (209) 468-3400 <br /> ltE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor licensing and <br /> Wotkman'ss Compensation Insurance requirements, we are asking that you provide this <br /> Depurttuent with the Information requested wlow. Please answer all of the questions and <br /> return the original of this letter to Public Ilealtli Services Ettvirottmomal Ilealth Division. <br /> Roll V111111011, Director <br /> 'Cttvirontucotal 110111111 Division <br /> BUSINESS NAME American Environmental Management Corporation (AEMC) <br /> IJUSINESS ADDRESS 9719 Lincoln VillageDrC1'VY Sacramento ZIP 95827-3332 <br /> I)USINFSS 'TLEI_EPl ION (1) (916) 364-8872 (2) (916) 985-6666 <br /> OWNER #1 Mr. Cliff Ronnenberg OWNER #2 y <br /> ADDRESS 11292 Western Avenue ADDRESS <br /> PI ZONE NO. (714) 826-9040/9049 131 IONS NO. <br /> o EXP DATE <br /> /23/g4tO��/92 <br /> (:.A., CON 1'1ZACfOtt LICENSE NO. 464159 ISSUE DA`1'�� . -. <br /> LICENSE CLASSIFICATION (A, far C) A If "C" INDICATE SPECIALTY NOS._ <br /> ASB and HAZ <br /> IF "C-61" CLASSIFICATION, INDICATE. TYPES LIMITED SPFCLALTY/IES <br /> ARE TME LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDINQ11 YES X NO_ IF YOU ARE SUl3JV01' TO WORKMAN'S <br /> COMPENSATION LAWS OF CAL.IFORNIA1 DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES_x_NO_.._ <br /> IF YESr HAVE YOU FILED A CERTIFICATE OF INSURANC w,l - 1WWs <br /> DEPARTMENT? YE5 x NO_ i YES, vxpmR ' D Ja n .• , 11 <br /> o ne erg <br /> SICNA'fURI: 14 N 11 1991 <br /> MENTAL HEALTH <br /> DATE .14Q 6:3/ PEWT/SERVICES <br /> 1111 QU 09 <br /> A 1livisi"q ul Sa")u:uluirr I'uuu,lr ilr�l,h I'uc 5iviul <br />