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. T • • <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT .SERVING <br /> James Culbertson, Pros. City of Lodi <br /> E. Vannuccl, Secy. <br /> Tommy Joyce 1601 East Hazelton Avenue, P. O. Boz 2009 San Joaquin County <br /> Tommy City of Esoelon <br /> Fern <br /> Earl Plmentel Stockton, California 9$201 City of Manteca <br /> bee <br /> Daniel <br /> L.L. Flo Florss 209/466-6781 on <br /> John 0. Mut, M.D. <br /> City <br /> of Stockton <br /> City of Tracy <br /> HealthWIIII•m J. Wade Jopl Khenn•, M.O., M.P.H., District Health Officer San Joaquin County <br /> Mary Anne Love 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, we 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 <br /> BUSINESS ADDRESS CITY ZIP <br /> BUSINESS TELEPHONE NUMBERS ( 1 ) (2) <br /> OWNER(S) ( 1 ) 1 (2) <br /> OWNER(S) ADDRESSES ( 1) (2) <br /> OWNER(S) PHONE NOS ( 1 ) (2) <br /> CA. , CONTRACTOR LICENSE NO. ISSUE DATE EXP. DATE <br /> LICENSE CLASSIFICATION (A,B ,C) IF "C" INDICATE SPECIALITY NOS. <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 NO <br /> IF YOU ARE SUBJECT TO WORKMAN' S COMPENSATION LAWS OF CALIFORNIA, DO YOU CARRY <br /> WORKMAN' S COMPENSATION INSURANCE? YES _ NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT? YES NO <br /> IF YES , EXPIRATION DATE <br /> SIGNATURE <br /> TITLE <br /> DATE <br />