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ANNVII1ONMENTAL HEALTH DTVI <br /> 445 N.SAN JOAQUIN <br /> STOCKTON, CA. 95201 <br /> (209)468-3420 <br /> CALIFORNIA L.LCENSED CONTRACT9T10NNAIRE <br /> Please complete all questions and return. This Information is required in order to <br /> comply with STATE and LOCAL LAWS. <br /> NAME: Rita Mendez 08A: Pacific Excavators <br /> BUSINESS ADDRESS: P.O. Bog 968 CITY: Alamo , CA ZIp 94507 <br /> BUSINESS PNiONE:t l0I 370-8783 PHONE #2 1510E 939-9044 FAX <br /> OWNER #I Rita Mendez OWNER #2 <br /> ADDRESS: P.O. Bog 968 , Alamo, CA 94507 ADDRESS: <br /> PHONE: 1101 370-8783 PHONE: 1 <br /> CALIFORNIA CONTRACTOR LICENSE NO. 605513 DATE OF EXPIRATION: 10-31-96 <br /> LICENSE CLASSIFICATION IA.B;C1 A LIST SPECIALITY# <br /> HAZARDOUS WASTE CLEAN-UP CERTIFICATION? Y XX N_ CERT.# 5453 <br /> CONSULTANT _ n/a <br /> ARE LICENSES LISTED CURRENTLY ACTIVE AND IN GOOD STANDING? Y XXN <br /> DO YOU HAVE EMPLOYEES? Y— N XX <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 /> Inform--tion below. <br /> NAME AND ADDRESS OF WORKMAN'S COMPENSATION CARRIER; <br /> NAME: <br /> ADDRESS: <br /> PHONE: AGENT <br /> EXPIRATION DATE: <br /> SIGNATURE: <br />