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b1/14/2UU8 14:58 5182374574 PRECISION SAMPLING PAGE 02162 <br /> 0IJI5/2009 IG:09 2095224227 ^.` i � 4J 99IGAL TEC-INICS PAQE 03 <br /> p� 1 9 200 <br /> Er.Vti F.J Nr:ryf:,; I <br /> 0 Joaquin County Envtronmantal Health ,ePartment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SRS!: <br /> LIOIENSED CONTRAOTORS DECLARATIONL( Cp} <br /> I hereby affirm that I am licensed under the proylsbns of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Profemsiona Cade and my llliense is in full force and effect <br /> License#:�t'p�2� n,.Expiration Date., j I Q�j <br /> Date: . ^,Gontractor. F'.t C� i i 4-Al <br /> Signature: Title• �.- <br /> Printed name; <br /> WORKERS' COMftNSA7ION DECLARATION <br /> I hereby of irrn under penalty of perjury one of the'fbllowing deoierotiona: (CHECK ONE) <br /> I have and will maintain a oerfificate of censer[to self-Insure for workers'compensation,as provided for <br /> by 5ectlon 3700 of the Labor Code,for the pO, ormenne of the work for which this permit is issued. <br /> J Fh ve and will maintain workers'wmpensati6:6 insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the wads for which thla�ermit is i trued, My workers,'compensation insurance <br /> caller and policy numbers are: <br /> Ganser: L t 6e—✓ W1 Policy Number: 3 �' <br /> 1 oeriffy that in the performance of the wools fogrwitiGh this permit Is issued, I shall not employ any person in <br /> any manner so as to become subject to the WJ Aers'compensation laws Of California,and agree that if I <br /> should become Subject to the workers`opmpd. tipn prov+8i6n3 of Section 3700 of the labor Code,l shall <br /> forthwith comply with those provislons, <br /> Expiration Date• o Signature: <br /> Printod Name. - .:C. �aC <br /> WARNING;FAILIJrAe TO SECURE WORKERS'CO NSATION COVERAGE 15 UNLAWFUL,,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIt.l.FINES UP TO ONE HUNDRED THOUSANb DOLLARS <br /> (9100,000.),IN ADDITION TO THE COSI'OF COMPERPATTON,INTEREST,ATTORNEY'S r-R ES,AND DAMAGES AS <br /> PROVIDED FOR IN Sec-rim 3706 OF THE UkDOIz rODE <br /> AUTHORIZATION FOR O_ THBR T"AN G-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorized rapromantativa). <br /> hereby authorize(print name} <br /> to sign this San Joaquin Count,Y Well Permit ApplIcAon an my behalf. I understand this auther[Won 13 valid for <br /> one(1)year and Is limited to th6 work pian dated on the front page of th1G application- <br /> 0.29.021 MI <br /> EUP <br /> G/2210s <br />