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Oct 26 01 03: 04p Sp estrum Exp. 20P- 1-65-8773 p. 2 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: P)rbpK , r+UM?S4a0!1 PERMIT SR#: 2 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Goole and my license is in full force and effect. <br /> License A C57# 512268 Expiration Date: 04/30/2003 <br /> Date: 01V0161 Contractor: Spectrum Exploration, Inc. <br /> Signature: Title: Operations Manager . . <br /> Printed name: Brenda rawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> 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 required by Section 3700 of the Labor-Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier, American Motorist Policy Number: 3BG03575800 <br /> _i certify that in the perfonnance 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 the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation prov ions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date-t V f 7&1 0 Signature: <br /> Printed Name: Brenda C wtord <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, Brenda Crawford of Spectrum Explor.(signature ofC•57licensed authorized representative), <br /> hereby authorize(print name) L11,fAal I <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 5-17-20001 MI <br />