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PUBLIC HEALTH SERVICES <br /> , —1 <br /> COUNTY0: c) <br /> -,4 <br /> SAN JOA(�UIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> I lealdl Mica C <br /> RO. Dox 2009 (1601 Fast I I jzc I(on Avenue) Scock-ton, Ca I i for nij 95201 ,cr0 <br /> (209) 468-340o <br /> g"T/Ij <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 /> Department with the information requested below. Please answer all of the questions and <br /> return the original of this letter to Public I lealth Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME Han5er, Z-nQlne-P <br /> BUSINESS ADDIZESS--Ll 2.- Pe- poe-re I I CITYZIP 95639 <br /> BUSINESS TELEPHONE (]).707Z-1-51 /360 (2) <br /> OWNER #1 Rrian OWNER #2 <br /> ADDRESS //.2 Pc-agerell Varac,,11,le- ADDRESS <br /> PHONE NO. 707 Y,5/ n 5 1-/O PHONE NO. <br /> E N G1 rj E e R, <br /> CA.,A., C-E)?4:FRAC-+e LICENSE NO..3� 3 19 ISSUE DATE 1491 EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) IF "C" INDICATE SPECIALTY NOS.— <br /> C- iut I Enty)e-erjy) Q <br /> IF "C-61" CLASSIFICATION, INDICATEtYPE/S LIN41-YED SPECLAUI'Y/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES v1 NO IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES NO Alc 7- 5 016 T E C-7r <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE wrri-i THIS <br /> DEPARTMENT? YES— NO— IF YES, EXPIRATION LATE_ <br /> SIGNATURE2At&-4A-, A-1'-a� <br /> TITLE Pres jjenT <br /> DATE- Au2us-r 29 / 99 1 <br /> I'M 00 09 A Division of Sin juAquin County I kilili Cire Scrvitus 0 <br />