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I <br /> 11110"D OF TiAUSTM <br /> SAN JOAG?UIN LOCAL HEALTH DISTRICT SERVING <br />�Jat>ttaa culbnft&m. Pries. City of Lodi <br /> Patricia E. 1lannuCal, s.oy. 1801 East Hazelton Avenue, P. O. Box 2009 San Joaquin County <br /> RomTy Joyce Clly of E�caion <br /> IEad PIRUMI'I Stockton, Cal Ifornla 95201 City of Escai ca <br /> wn Bullb" City f m nieca <br /> D&nlet L. FIorN 209/466-6781 <br /> City of Stocklun <br /> Ripon <br /> go" 0. Mut, M.D. City of Tracy <br /> NIIUam J. Wade J*9I Khanna, M.D., M.P.H., District Health Officer San Joaquin County <br /> Mary Anna Low <br /> San Joaquin County <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 , vie are asking that you provide this <br /> District with the information requested below. Please answer all of the questions <br /> and return the original of this letter in the self-addressed envelope provided . <br /> Ron L. Valinoti , Director <br /> Environmental Health Division <br /> BUSINESS NAME Aqua Science Engineers, Inc. <br /> suite <br /> BUSINESS ADDRESS 2500 Old Crow Canyon Rd CITY San Ramon ZIP 94583 <br /> BUSINESS TELEPHONE NUMBERS ( 1) (415) 820-9391 (2) (415) 820-1850 <br /> OWNER (S) ( 1) William F. Rusk (2) David Shultz <br /> OWNER (S) ADDRESS ( 1) 17 Cathy Lane, San Ra4&) 251 Lugonia, Newport Beach <br /> OWNER (S) PHONE NOS ( 1) (415) 837-4153 (2) (714) 631-2313 <br /> CA. CONTRACTOR LICENSE NO. A487000, C-57 ISSUE DATE 2-29-90 EXP. DATE 2-29-92 <br /> LICENSE CLASSIFICATION (A,B,C) A IF "C" INDICATE SPECIALITY NOS. C-57, HAz <br /> i <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALITY/ IES . <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING? YES X NO <br /> IF YOU ARE SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN'S COMPENSATION INSURANCE? YES X Certificate Attach®d <br /> i <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES NO_ <br /> IF YES, EXPIRATION DATE 8-15-90 <br /> SIGNATURE $ �� <br /> a <br /> TITLE <br /> DATE 0 <br /> i <br />