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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOCI KHANNA M.D.,M.P.I1. M' - <br /> IIe3llh Officcr <br /> P.O. flux 2009 . (1601 Fast Ifazrlewc Avenue) . Scockwn, California 95201 f�ico.n � <br /> (209) 468-3.100 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor licensing and <br /> Workman's Compensation Insurance requirements, we are asking that you provide this <br /> Department with the information requested below. Please answer all of the questions and <br /> return the original of this letter to Public I lealth Services Environmental f lealth Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME SB&S ENVIRONMENTAL DRILLING <br /> BUSINESS ADDRESS 3022 W. SANTA ANA CITY FRESNO ZlP 93722 <br /> BUSINESS TELEPHONE (1) 209-227-8288 (2) <br /> OWNER #1 Richard Short OWNER '12 Vern Smith <br /> ADDRESS 3022 W. Santa Ana ADDPZESS 3022 W. Santa Ana <br /> PHONE NO. 209-227-8288 PHONE NO. 209-227-8288 <br /> CA., CONTRACTOR LICENSE NO. ISSUE DATES/10/8EXP DATE 3/31/93 <br /> LICENSE CLASSIFICATION (A, B, C) C IF "C" INDICATE SPECIALTY NOS. <br /> C57 560175 <br /> 1F "C-61" CLASSIFICATION, INDICATE TYPE/S LIMITED SPECIAL'L'Y/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES X NO 1F YOU ARE SUBJECT TO WORI-IAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES X NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WTTuI rHis <br /> DEPARTMENT? YES_ NO_ 1F YES, EXPIRA'T'ION DATE 8/1/91 <br /> State Fund 1188 7 <br /> -90 <br /> I <br /> SIGNATURE <br /> TITLE Partne <br /> DATF <br /> l.'If 00 09 <br /> A Division ur Sin JuatIuin Cuunry I Icilii,Circ scrvitrs <br />