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r <br /> G d I k110.i <br /> 1110ARO of TAUSIM SAN JOAOUIN LOCAL HEALTH DISTAIG{r4"y aiEertvirt= <br /> %ut"64 culbarlson. Prdi. City ofLoc <br /> r6tekla C. vannwtS:l, t}k'r 1541 Ea3t Htlzelton Avenue. P. 0. Box 2009 blA JoaQuln C4un1 <br /> Ton,mr loyte City*f CCcalo Earl vtm.nS.S Stockton. cdkillornia 9520! CISr of Man;K. <br /> Fein Super+ y� Cltyof RIP-0( <br /> 0sntal L. Florae 209/466-6761 i1 (['��� ��` �} Cljy of tltockto, <br /> ,l*hn 0. MG,t, M.D. V V i. U CnrorTrac;, <br /> William J. Wade JOai KWAA, M.0„ M.P,H,l 0161110 +i 6th gtflcsr ban Joaquin 00unl� <br /> Mary Anna Love MAY 1 1989 San JoaqutnCount) <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 returns the original of this letter in the self addressed envelope provided. <br /> Hun L, val inut i , oi.lcec Lor <br /> Envit•nl m(� ntul Ifeultn Uiviuion <br /> BUSINESS NAME 4 ��, (i <br /> BUSINESS ADDRESS (. W s ,CITY CJA d(.tJ' �11P 9u5e <br /> QE NUMBERS �} <br /> BUSINESS TELEPHONE <br /> OWNER(S) ( 1 ) r (2) J �LL L,______. <br /> OWNER(S) ADDRESSES ( 1 ) •rc sc. Uj utj K) -ka r C . Q �� l <br /> OWNER(S) PHONE NOS ( I) 0H) 7 c� �. <br /> CA. , CONTRACTOR LICEI1SIr ra0. _-.. ISSUE DATE EXP. DATE - -9D <br /> LICENSE CLASSIFICATION (A,R ,C ) IF "C`. INDICATE SPECIALITY NOS . <br /> IF ,'C-61 CLASS IFICATIbt+, INI)ICATE fY fI'/S OF t. Iml II:O 5111.ClAt I TY/ It'S <br /> UIMIP <br /> ARC TIIE LICENSES LISTED "OVE CURRENTLY ACTIVI AND IN GOOD STANDING? YES , 140 <br /> IF YOU ARE SUBJECT TO WORKMArf-S COM r 5AT [ON LnuS 0� CAl IFUkNIn, 00 YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES, P.� NO .__ •- ------ __-- _ <br /> If YES, HAVE YOU FILEO A CERTIFICAtE OF INSURANCE wIT11 Tt1IS OISTRICT? YES ff0 <br /> IF YES , EXPIRATION OATS <br /> SIGHATURE <br /> NATE <br />