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PUBLIC HLALTH S <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />CONTRACTUR/C;ONSULI'AN'1' QUES110NNAIRE FAX: (209) 464-UI38 <br />LICENSE # 5g2n1 n DATE ISSUED 5 / /go EXP ISSUED 5 / /2000 <br />LICENSE CLASS 1A HAZ LICENSE CLASS 2 B LICENSE CLASS 3 C-10 & C-21 <br />"C" SPECIALTY # 21 & 10 <br />TYPES OF LIMITED SPECIALTY (IES) <br />LICENSE IN GOOD STANDING? Py N WORKER'S COMP 1 Y 1 N <br />PRIMARY QUALIFYING INDIVIDUAL: <br />A Division of San Joaquin County Health Care Services <br />