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1 1 : 1 4At� FROA•1 <br /> i <br /> - P 2 <br /> CONTRACTOR/CONSULTANT QUESTIONNAIRE. <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAC UIN COUNTY i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388 STOCKTON CA 95201.-0388 <br /> FOWNER INFORMATION <br /> BUSINESS NAME: <br /> ADDRESS : <br /> lb Yn, <br /> F CITY/STATE/Zip: C.q.syo <br /> r 4 E u V, <br /> S <br /> PHONE NO ( 5 o) g g -;;p PHONE NO 2 ( } <br /> FAX NO ( ) <br /> O'rINER #1 INFORMATION <br /> .OWNER #t2 INFORMATION <br /> NAME: v y^` ;-- NAME: <br /> ADDRESS . <br /> i ADDRESS <br /> CITY: ,T <br /> CITY. <br /> STATE . -74ZIP . ? <br /> - STATE : ZIP: <br /> .LICENSE INFORMATION <br /> F. CA. CONTRACTOR LICENSE ���r � t {, �; ]TATE ISSOED / / EXP DATE o � <br /> i <br /> ' LICENSE CLASS I LICENSE CLASS 2 <br /> LICENSE CLASS 3 <br /> "C" SPECIALITY VIS �,_ H 7 <br /> TYPES OF LIMITED SPECIALTY (IES) <br /> FLICENSE IN GOOD STANDING? Y N WORKERS S COMP INSURANCE O N <br /> WORKERS COMP INSURANCE CERTIFICATION ON FILE WITH E.H. D. ? Y <br /> EXPIRATION DATE 1 / / 0 v <br /> gAZARDOUS WASTE CLEAN UP CERTIFICATION? yO N <br /> CONSUL'T'ING FIRM INFORMATION <br /> .SITE MITIGATION CONSULTING FIRM? OY N SAMPLING FIR!~I ONLY?--Y- r] <br /> GA REGISTERED OR CERTIFIED GEOLOGIST/ENGINEER? O N <br /> PRIMARY QUALIFYING INDIVIDUAL: <br /> P,r: Lc- vv: c <br /> ,�fp/ENGINEF}2ING RE(;/C`CRT N1J-MRP-R : G c -�5 o <br />