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JAN-02-2001 12:51 FROM PRECISION SAMPLING TO 15102354355 P.01 <br /> Sara.io��tdi¢C.Oun y p� �r� <br /> Him tb swvi�Ur""f•IV.Well Pat'rolt � plyterr�teeat <br /> JOB ADDRI�S& 3'7Ao <br /> TION (LC <br /> UCEASED d(.s4 ri+ CONTRACTORS <br /> thereby of tTn that i am i� ornsed under ttte proyis3or+s orf met 9(=rr►eryrrng wdh Section 7000)of Desch w <br /> 3 of the 8tlsin 3 <br /> : s and M Gide and my»e*►s�e is im tug fie and cited. <br /> - ) <br /> Licerts8# _ 63 6.3g1:� 6cparabw we; <br /> OQ <br /> PrEnfed name: <br /> woRKEfw =upmS mom DECLARATION <br /> jnix�Z"7:under.Pero*d poury one of ft UIWAng : (CHI=CK ALL"nIAT AIL`f} <br /> t trace-acrd wifD rrwir�tain a of Consent to Wtfj�lre'4or wcxfa 'compensation,a�pcarnded for by 1 <br /> ...__bion 3240 of the L abor Code,Wthe PerlLorMV%*e afthe workthr v* 'bis Derrn�t is i:tstn`a. � <br /> I have and wrtr ma&AW wOOMW="Pw0dW kmuranoe,as required by Seetlon 3700 of The Labar COW- <br /> .fior the ps"srrtenoe <br /> arvov"kfor v#chthisPerfrAis Im . My Wks'cr MWsatbn hs.urasoo <br /> CwHer amd pati/cY rtuLrrr ars.�+e: <br /> Cazrtot: G, 5c roti � ' 1 Policy awnher. L)C I 8-71-o-)2.339 <br /> _ f y y r tf18t perfoftrranoe of rile trrork foc wtkh"pwnit is issued, 1 shall not GMPIOY SnY Person ai <br /> any rnantwr so as to became subieot to the worker: compensaw kaws of Cali amts.and agree twt if 1 <br /> should booms suljeot to the nwrkea'S'can p�risie�s of SOQio+i 3700 of tta Labor Cade,1 stmt <br /> _._7.7..._... :I Mose w"10M. '\ <br /> Date: err '. SitgrGaWnr <br /> Printed Dams: <br /> vir�t�weit�:PA&UM TO MRIMM C NSaT1OAr es LiAdA011lF7JL.AWS SHAT l_sut3i@CT <br /> Art 'RTO CPMRAL PERM.11W AIS"OIL FRAM tom+"OtiF- M& THOtJ8AliO DLiI►r� <br /> jSjO& 00,l,IN#DWn=To Trig CWr c*W N&MATiat4 Wyf=n.AT ORNgv°S FEM AM VUW3W&S <br /> PWMDM FOR nil 3MOFTfMf iiWRCOLM <br /> - � �Sr: >�8 afCr57 tie�nsed aWimr�d�P� <br /> erg <br /> (pant <br /> n _ ���k �- ��� ' �' <br /> bo.ign thSs Sa j=*jn county%W1Pet wdt w oa Wb6h8lt t.eridemfted th►s UlAWIN a OM L; .for <br /> orae 0)Yews b aw wade.pian aamsa on crus fioett p�of'tpu;aPpttcad eau <br /> s-t�- ao r air'A <br /> i <br /> Post-it*Fax Note 7671 Date a� �_ nagg°est <br /> To // From <br /> Go./Dept. Co. <br /> Phones Phone 4 <br /> Fax# 31,- Fax# <br /> I � <br /> TOTAL P.01 <br />