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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> a: a <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Dox 2009 • (1601 Easr Hazeltun Avenue) Stockton, California 95201 <br /> (209) 468-34100 <br /> PAYMENT <br /> RECEIVFr <br /> OCT 0 3 1997 <br /> SAN JOAQUIN CU:,! <br /> PUBLIC HEALTH <br /> ENVIRONMENTAL HEAD f i L.Vi6toN <br /> RE: CALIFORNIA LICENSED CONTRACTOR QUESTIONNAIRE <br /> In order to comply with State and Local Laws relative to contractor <br /> licensing and Workman 's Compensation Insurance requirements, we are asking <br /> that you provide this District with the information requested below. <br /> Please answer all of the questions and return the original of this letter <br /> to Public Health Services Environmental Health Division. <br /> Ron Valinoti, Director <br /> Environmental Health Division <br /> BUSINESS NAME <br /> BUSINESS ADDRESS fir, l`s c pc#5 CITY ZIP <br /> BUSINESS TELEPHONE (1) <br /> OWNER #1 .__�c�� �. � v.c.h OWNER #2 L��.�c�1�. <br /> ADDRESS j 9 1 FAA I y;� � r *1� ` ADDRESS �J \ Ca• <br /> PHONE NO. C��t ��% - /. _ PHONE NO. �'`i <<3 1 <br /> CA. , CONTRACTOR LICENSE N0. � I ,7-)c _ ISSUE DATE �lqZ- EXP DATE �3 <br /> LICENSE CLASSIFICATION (A, B, C) (6L IF "C" INDICATE SPECIALTY NOS. <br /> IF "C-61" CLASSIFICATION, INDICATE TYPE/S OF LIMITED SPECIALTY/IES <br /> ARE THE LICENSES LISTED ABOVE CURRENTLY ACTIVE AND IN GOOD STANDING?&) N <br /> IF YOU ARE SUBJECT TO WORKMAN' S COMPENSATION LAWS OF CALIFORNIA, DO YOU <br /> CARRY WORKMAN' S COMPENSATION INSURANCE? YES NO <br /> IF YES, HAVE YOU FILED A CERTIFICATE OF INSURANCE WITH THIS DISTRICT?� 11 <br /> IF YES, EXPIRATION DATE <br /> SIGNATURE <br /> TITLE <br /> DATE <br /> A Divisinn(if S.m Joaquin County 11c.ilth Care Scrvitvs <br />