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P UBSERVICESIC HEALTH <br /> SAN JOAQUIN COUNTY r: <br /> JOGI KHANNA M.U.,M.P.H. r?I <br /> Health Officer <br /> P.O. Box 2009 . (1601 Gast Hazelton Avenue) • Stockton,California 95201 9(460 ` <br /> (209) 468-3400 <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor <br /> licensing and Workman's Compensation Insurance requirements, we are asking <br /> that you provide this District with the information requested below. <br /> Please answer all of the questions and return the original of this letter <br /> to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME Murray & Associates Environmental Services <br /> BUSINESS ADDRESS 5051 Lexington Circle CITY Loomis ZIP 95650 <br /> BUSINESS TELEPHONE (1) (9161 652-0458 (2) FAX (916) 652-0464 <br /> OWNER 11 Kent S. Murray, Ph.D. OWNER 12 NA <br /> ADDRESS 5051 Lexington Circle, Loomis, CA ADDRESS <br /> PHONE NO. (916) 652-0393 PHONE NO. <br /> CA. , CONTRACTOR LICENSE NO. 631513 ISSUE DATE 10/31/91 EXP DATE 10/31/93 <br /> LICENSE CLASSIFICATION (A, B, C) A.HAZ, C IF "C" INDICATE SPECIALTY NOS. 57 <br /> IF 11C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? NX N <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN'S COMPENSATION INSURANCE? YES — NO Not Applicable <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? Y N <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE bwner <br /> DATE 1/28/93 <br /> A Division of San Joaquin Coonty HeaItIt Care Services �' <br />