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l <br /> 09/27/2007 15:25 FAX 7149096759 TESTAMERICA DRILLING Z002 <br /> .�r " ., .,.,.cvl+ �ty,WlIItJlltid �liwnra `brP 916-6,�41 p,3 <br /> I <br /> FWtheaLW" ' <br /> in Cotlrliy Lnviranmental HealRat Oepartmtrnt Anil IV Well Permit APp�ttott&nppfenterlt <br /> ESS: 3313 E. Char r rim PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION L( Cl2 <br /> Ithal I am NCerlSeb under 1tle Provisions Of Chapt e 9(commencing with Serdren 70Co)of DIvlSion <br /> 30 and Prvfesslons Code and my license I$In Ful force and affect. <br /> Ex iratlCn a: 51 Z <br /> Date: 2 Contractor �Sf 1 m <br /> i <br /> Signature: 1qe: enefZ�t _ �Qncz� (� <br /> Printed name- <br /> 1.11 <br /> WORKERS,co NSATION XCLARATION <br /> I hereby affirm under penalty Jof perjury one of the following dec# abons: (CHECK ONE) i <br /> h®vo and v44 malalain a rertifioste of consent to self•insu lfor+Nartcers'co <br /> by Section 3700 Of the tabor Cade,for Ihs rnpetl8ati�►,as sed. ad fur { <br /> perforrnartce of a work for'yphich this pemtil Is issued. <br /> I have and will mail"In waKers,eornpensatipn inc e,a <br /> for the perform nm of the work for which this pe mtR is issue , M inm by S'' cation ti 370 of the Labor <br /> de, <br /> the <br /> and policy numbers are: <br /> Carrier. Ch * �� <br /> �. PeitCy N ur rkber, <br /> I CMIY Thar in the peffbm enft Of the vmrk for vri'Iich this pe t7 is issued, I shall not employ any person in <br /> any manner so OR to beftrn&sub)ect Io the workers'Oompe salon 19ws Of CalirOmia and agree t1+at if I <br /> shplrld become subject to file wArfoers'compensaWn provisio s Of Section 3700 of the <br /> forthwith comply with those proYislans. J.aber�Ode,I s#zSR <br /> Fspirationbane. d'-u/-dS -signature; u ' ad6; <br /> PriMett <br /> WARNING:FAItUItE 7V&ECURE WCRKE COIMIPSNGATION COV RAGE IS UNLAWFUL.AND&HALL SUBJ407 <br /> AN EMPLOYER TO CRIMMAI.ftNALTIeS An CIVIL FINES VP To C HE HUNDRED THOUSAND DOLLARS <br /> (i100'000'R IM ADDITION TO THE COSY OF 6011PIEWSATION,INTM taT,ArlORNEY-S FC-1155,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3"6 bit THE LABOR C 30E. <br /> AUTHORIZATION POR+DrHER THAN C-57 SIGNING PERMIT APPLICATION <br /> All' fyh <br /> C,-f �- e"Ca0%.,— <br /> — (3'Onsfu re <br /> t oriG7 arrhsed aylhorzed ropreseretative�, <br /> h9mby butimize(pefe name �r�_.l ra Q on-v c yr <br /> tv srgn this San JcaQtiin CO11nty Well PermitApplicativn an my behaii, I Vr'd@mtN"d 1h(9 00110ftaftn K valid for j <br /> one(1)year and is limited to theWark plan tlited antbefront paao ofithft application. <br /> 8-29x!1W <br /> I <br /> END 29-02-091 <br /> nnCJl.,JQ9 <br /> Ii t 2i844WU @S_9 T Lp10z-L -d3S <br />