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James Culbertson, Pros. <br />R` Patricia E. Vannuccl, Secy. <br />Tommy Joyce <br />Earl Pimentel <br />Fern Butibee <br />Daniel L. Flores <br />John D. Most. M.D. <br />William J. Wade <br />Mary Anna Love <br />LOCAL riEAL FH UIS I HICT SERVING <br />City of Lodi <br />East Hazelton Avenue, P. 0. Box go San Joaquin County <br />Stockton, California 95201 City of Escalon <br />City of Manteca <br />209/466-6781 City of Ripon <br />City of Stockton <br />Jo®l Khanna, M.D.. M.P.M., District Health Officer Cof Tracy <br />San Joaquui n County <br />San Joaquin County <br />1992 <br />EVI PERMIT/SERVICES /q/H�LTH <br />E I 0 Y IIs <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 />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 />Ron L. Valinoti, Director <br />Environmental Health Division <br />BUSINESS NAME SG 1 �'Z. W/ ''7H/ <br />BUSINESS ADDRESS-` Lr />pL�C ST CITY _�'®Liu. 0,4, ZIP 2/6 <br />BUSINESS TELEPHONE NUMBERS (1) Z®g 13r -681f (2 ) <br />OWNER -(S.) (1)/�LQ41 LR- AIOt (2) <br />OWNER(S) ADDRESSES (1) _�C (2 ) <br />OWNER(S) PHONE NOS (1) S&QC (2) <br />CA., CONTRACTOR LICENSE NO. t-Isss 3 ISSUE DATE EXP. DATE 5a�_ <br />LICENSE CLASSIFICATION (A,B,C) _t4 I IF "C" INDICATE SPECIALITY NOS. <br />IF "C-61" 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 COMPENSAT ION .AWS OF CALIFORNIA, DO YOU CARRY <br />WORKMAN'S COMPENSATION INSURANCE? YES f/' NO <br />IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES NO ✓' <br />IF YES, EXPIRATION DATE <br />SIGNATURE,`/ <br />TITLE <br />DATE <br />EH 05 30 1_86 <br />