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ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN <br /> STOCKTON, CA 95201 <br /> (209)468-3420 <br /> CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> Please complete all questions and return. This information is required in order to <br /> comply wi <br /> th STATE and LOCAL LAWS. <br /> NAME: gtk&YOM6 -"'DBA•. �jgj jjl Y}g C=72aG <br /> BUSINESS ADDRESS: 0136S W jQJLA M �W. CITY: ,'�C,�T� ZIP Q�C7 <br /> 1 BUSINESS PHONE-0 LIDS- $-? 1�— PHONE #2_( )T <br /> OWNER #1 OWNER #2 <br /> ADDRESS: ADDRESS: <br /> PHONE:-�- -)- _ PHONE. ( ) <br /> CALIFORNIA CONTRACTOR LICENSE NO DATE OF EXPIRATION: Y 97 <br /> LICENSE CLASSIFICATION (A,B,C) LIST SPECIALITY# <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y_ N_� -CERT # <br /> CONSULTANT <br /> ' ARE LICENSES LISTED CURRENTLYfTIVE AND IN GOOD STANDING? YL N <br /> DO YOU HAVE EMPLOYEES? YN_ <br /> ' If you answered NO to above, please complete attached waiver and submit with i <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: e Yl ` ASS 0 ( T'_S <br /> ADDRESS; �L4 <br /> ' PHONE, b' AGENT 3IE . C- <br /> EXPIRATION DATE —9 <br /> SIGNATURE* <br /> r <br /> Page I4A <br />