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Oct 09 01 01 : 48p Sp-*,tram Exp. 2065-8773 p. 2 <br /> E.- i0 <br /> 1 <br /> San Joaquin County Environmental Health Services, Unit 1V Well Permit Applicati n Supplement <br /> JOB ADDRESS: PERMIT <br /> SR#: �� <br /> �� r <br /> LICENSED CONTRACTORS DECLARATION U-2) <br /> I hereby affirm that I am licensed under the provisions of Cha ter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in f ull force and effect. <br /> License#: C57# 512268 Expiration Date: 04/3012003 <br /> Date: q Contractor: Spectrum Exploration, Inc. <br /> Signature: <br /> 'Title: Q erations 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 I he work for which this permit is issued. <br /> Xy, I have and will maintain workers' compensation insuranc , 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 umber: 3EGO3575800 <br /> I certify that in the performance of the work for which this permit is issued, k 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 ons of Section 3700 of the Labor Code, I shall <br /> forthwith cornpiy with those provisions. <br /> Date: /6'Mw Signature: <br /> Printed Name: Brenda C word <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATIO 4 COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FIDES U:1 ESTTo ONEHUNDRED,ATTORNEY'S FEES,AD DOLLARS DAMAGES AS <br /> PROVIDED OR IIN DN SECTION 3706 OFTHE DITION To THE COST FLABOR CODEION, <br /> I Brenda Crawford of Spectrum Explor-I signature ofC-57 licensed authorized representative!, <br /> hereby authorize(print name) 1/ � � � `"- °T /�G �iV�• <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 /> 5-17-2000/Ml <br />