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ENVIRONMENTAL HEALTH DIVISION <br /> 445 N.SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209)488-3424 <br /> C�A�IFORNIA_LfCENSEDQQNIMCTO13 QUESTfONNALRE <br /> Please complete all questions and return This information is required in order to <br /> comply with STATE and LOCAL LAWS <br /> NAME- s2pfM(A ffl �x �QY�I�� �D`BA ll�i �3t Y'�g cm- I�2-4C-_lZF`� <br /> BUSINESS ADDRESS- WirALgM CITY: SAY rf l ZIP-2-2- _65 <br /> BUSINESS PHONE-01 PHONE #2,, 1 <br /> OWNER #1 1 OWNER #2 <br /> ADDRESS-- ADDRESS: <br /> PHONE: ( ? PHONE: ( _t <br /> CALIFORNIA CONTRACTOR LICENSE NO. * DATE OF EXPIRATION:_�L/ 97 <br /> ` LICENSE CLASSIFICATION (A,B,C) LIST SPECIALITY# <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y_ N_� CERT.# <br /> CONSULTANT <br /> ARE LICENSES LISTED CURRENTLYCTIVE AND IN GOOD STANDING? YL N <br /> DO YOU HAVE EMPLOYEES? Y-, N_ <br /> ' If you answered NO to above, please complete attached waiver and submit with <br /> questionnaire. If YES, please provide Certificate of Insurance and complete <br /> Information below. <br /> NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER, <br /> NAME. <br /> �i <br /> ADDRESS: <br /> PHONE:,S1�-L - AGENT KtL)ZniQg= <br /> EXPIRATION DATE: <br /> SIGNATURE:at <br /> Page 14A <br />