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_06/24/2005 15:59 2094658 �qq� � t SPECTRUM EXPLOR PAGE 01 <br /> 7C/l/ <br /> FJOEI <br /> m Joaquin County Environmental Health Department Unit IV Well Permit Application <br /> Supplement <br /> ADDRESS: C(/YyI(�/1/ ' `�7✓(G,4 l PERMIT SR#: X72 �9 <br /> „ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 3 ofrt eaffirm B siness and Professions Code andprovisions <br /> my license Is Chapter ull force and effect <br /> with Section 7000) of Division <br /> Lice�s 68 Expiration Date: 04-30-06 <br /> Dat(,- Con cto S ectrum Ex loration Inc. <br /> Title: Regional Manager <br /> Slgi tore: '— <br /> Printed name: <br /> RKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br /> I have and will maintain workers'compensation insurance,as requireodrbe ompensati nthe Labor nsti anceCode, <br /> for the performance of the work for which this permit is issued. My <br /> carrier and policy numbers are: <br /> Carrier: National Union Fire policy Number: 1177860 <br /> certify that in the performance of the work for which this permit is Issued, I shall not employ any person in <br /> any manner so as to become subject to rksra'Co nsatio4n ,,n ad agree that if I <br /> should become subject to the workers' ompensation provl ions e Lahor Code, I shallforthwith comply with those provisions.ExplrationDate; 04` 01 -06 Signature: <br /> Printed Name: <br /> )MPENSATFUL,AND SHALL <br /> WARNING:FAILURE TO q EMPOYER TO CRIMSNAL PENAECURE OTIES AND CVIIL Fi ESRKERS'CCI UP TO ONN COVERAGE IS AND DOLLARSUSJECT <br /> (PIIOVIDED FOR IN SECTION 9706 OF THE$,100,000 ,IN ADDITION TO T14E COST FLA60R COOECOMPENSATION, <br /> INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> n /ape r Fant �pature ofC-67 authorized representative), <br /> P] <br /> T Nom` <br /> hursby authorize(print name) <br /> tc sign this San Joaquin County Well Permit Application On mY behalf. I un erstand this authorization as valid for <br /> ate(1)year and to limited to <br /> the work plan dated on the front page of this application. <br /> 6.29.021 MI <br /> l 19.02-001 <br /> 6122n4 <br />