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G - 2 — 9 1 -r U �5 :_: W E = T G:: Hi=iN ' - EN P _ � 3 <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY Y <br /> JOGI KHANNA M.D.,MT.II. <br /> 11cal+h Uf icrr <br /> l �� <br /> P.U. Box 2U09 . (1601 Fast Itazeltun Avvnue) . Stockton,California 95201 '-� <br /> (209) 168-3100 <br /> • is <br /> RE.- CALIFORNIA LICENSED CONTRACTOR QUES'T'IONNAIRE <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 nll of the questions and <br /> return the original of this letter to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental I-lealth Division <br /> BUSINESS NAME_ Ha <br /> BUSINESS ADDRESS_J2. Pe n,� -rell CI'T'Y ZIT' 2 -56'99 <br /> BUSINESS TELEPHONE (1)10-2; / 13 G b (2) <br /> OWNER #1' Brian 1n sM _ OWNER #2 <br /> ADDRT;SSS/12 rQ,—j�Derell Va raw-&e- ADDRESS <br /> PHONE NO. 70 7 0:5.4Z_ PHONE NO. <br /> ENGIIVEE R <br /> CA., LICENSE NO. 323 19 ISSUE DATE ! 8 EXP DATE <br /> LICENSE CLASSIFICATION (A, B, C) IF "C" INDICATE SPECIALTY NOS.— 1' <br /> C- u t l E n t r <br /> IF "C-61" CLASSIFICATION, INDICATE YPE/S LIM! ED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD <br /> STANDING? YES NO� IF YOU ARE SUBJECT TO WORKMAN'S <br /> COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY WORKMAN'S <br /> COMPENSATION INSURANCE? YES_NO /Vo i S U6 T EC--r <br /> 1F YES, HAVE YOU FILED A CERTIFIC`ATE OF INSURANCE WT'I'T-i THIS <br /> DEPARTMENT? YES,_ NO— If YES, EXPIRA'T'ION DATE_ <br /> SIGNATURE ,Alad�� <br /> Tl'rLE P_ fes j denT <br /> DATE Auo us-r 9 9 <br /> FII ao 09 <br /> A Division u1 S.4n jusquist Cuucuy l{erAh Cive Services <br />