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PUBL C HEALTH SEtVICES <br /> SM JOAQUW COUNTY <br /> JOGI l(HANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O.Box 2009 • (1601 East Hazelton Avenue) • Stockton,California 95201 ji 641 <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 LAWRENCE LIVERMORE NATIONAL LABORATORY <br /> BUSINESS ADDRESS . 7000 East. Ave. - CITY Livermore ZIP 94550 <br /> BUSINESS TELEPHONE (1) (510) 422-1100 (2) (5101 422-Qfi49 <br /> OWNER #1 . U. S. Government, D. 0. E. OWNER 12 <br /> ADDRESS — 1301 Clay St. - Oakland CA 94612 ADDRESS <br /> PHONE NO. (510) 637-1794 PHONE NO. <br /> CONTRACTOR LICENSE NO. N/A ISSUE DATE N/A EXP DATE N/A <br /> LICENSE CLASSIFICATION (A, B, C) _ILL_ IF 11C11 INDICATE SPECIALTY NOS._&L <br /> IF "C-6111 CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES N <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? Y N <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN'S COMPENSATION INSURANCE? YES NO X <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? Y N <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE Tank UDgrade Prgjggj_Ma13ager <br /> DATE 8 August 1993 <br /> A Division of San Joaquin County Health Care Services <br />