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ROARD ul TRU,. Pro SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Jain" Culbartaon, Pna. <br /> PaUkla E. vannucel, 30c,Y. SERVING <br /> Tommy Joyca 1601 Eaat Hazelton Avenue, P. O. Sox City of Lodi <br /> Earl Plmantal 2009 SanJoaqulncounty <br /> Forn Bupbaa0� Stockton, Caln'OTMT8-95201 city of Eacalon <br /> 0"1 L, Floras 9� 5��q 209/466-6781 City o1 Manleaa <br /> John d. Mast, M.O. 1� City of Ripon <br /> Wo"William J. City of Stockton <br /> Mary Anna Lova ,L JOp KhuyFC44.D., M.P.M., Olorki Haa1M olfkar Qty*1 Tracy <br /> 41"Joaquin County <br /> ,r 1`t7 3"Joaquin County <br /> SEP 21988 <br /> ENVIROMENTAL HEALTH <br /> FERMIT/SERVICES <br /> RE: CALIFORNIA-LICENSED CONTRACTOR QUEST1014NAIRE <br /> In order to comply with State and Local Laws relative to contractor licensing and <br /> Workman'sCompensation insurance requirements, we are asking that you provide this <br /> District with the information requested below, , Please answer all of the questions <br /> and return the original of this letter in the self-addressed envelope provided, <br /> [tun L. Valinoti , Director <br /> BUSINESS NAMEEnvironmental Health Division <br /> 1� <br /> BUSINESS ADDRESS 3U5.9 ,CITY �^, z-� IP — <br /> BUSINESS TELEPHONE NUMBERS ( t) -!7l ZIP <br /> OWNER(S) ( 1 ) U =�� _(2) !r Z 1- Oaf <br /> /' �tJ; (2) r p <br /> OWNER(S) ADDRESSES (1)j9/9Go3A[n� yF�� (2) 112- <br /> OWNER(S) <br /> /2OWNER(S) PHONE NOS <br /> (2) 21K Li=L7W _ <br /> CA, , CONTRACTOR LICENSE N0. ISSUE DATE <br /> DATE <br /> LICENSE CLASSIFICATION (A,B ,C) _C IF "C" INDICATE "SPPECIALITYXP.NOS. <br /> r <br /> IF "C-51 " CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/IES. <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING?' YES %' NO <br /> IF YOU ARE SUBJECT TO WORKMAN' S COMPENSATION L WS OF CALIFORNIA, 00 YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES NO <br /> � <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES NO <br /> IF YES, EXPIRATION DATE r/ - <br /> SIGNATURE <br /> TITLEDATE --.-- -�-- -- <br />