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r---- <br /> j San Joaquin County Environmental Hgfth�Wrbtwnt Unit N WebPermil Application supplement <br /> ' JOBACDRESS: i -Yz1 C. CancM �� r c PERMIT SR#: 5�5 ti <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby a-firm that 1 am licensed Under Cie provisions of Chapter 4(commenang with Secton 7000)of Division <br /> 3 of the Bssiness and Professions Code and my license is In full force and effect. <br /> Lir:ensett 636287 ExPIratlonDate. 1 /3112010 <br /> Date. <br /> Contractor. Precision Sampling, Inc. <br /> Signature '— <br /> ,lPrintedrame;.. <br /> Title+: LccaLion Manager <br /> wren is Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm unser penalty of pequry one of the following declarations: (CHECK ONE) <br /> i <br /> _ I have utd wial maintain a Certificate of consent to self-Insure for workers'compensation,as provided for i <br /> by Seclon 3700 Of the Labor Code, for the performance of the work for which this permit is issued. <br /> 1 have and wlb maintain workers' <br /> Compensation insumnce.as required by Section 3700 of the Labor Code, <br /> for the performance of the work for wtdctt this permit Is issued. � <br /> carrier and My workers'compensation insurance <br /> � policy numbers are: <br /> Cartier= ibeCty Mutual r �r Policy Number..yC_1B710723 3 9027 _ <br /> I certify that in the Performance of the work for which this permit is issued, I shall viol employ an <br /> any maaner so as to become"Oct to ft workers'axn P Y Y Parson in <br /> should WOOMn subject to the wakens'com visions Of Section <br /> of Catdornia, and a9rea that if I <br /> l0 tttvvitt comply with those Pensabon provisions of SeCticwt 3700 of the Labor Code, I shall <br /> i Provisions. <br /> Expiration Date: 6/3 012 0 0 8 <br /> Signature: , <br /> i - <br /> I Printed Name: Brenda Crawford <br /> A";R r:F-ULURE 1'0 SECURE WCrWERS'COAF'rENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S100,e004,IR ADOMON TO THE COST OF COMPENSATION,INTEREST ATTORNEY'S FEES,AND DAMAGES AS I <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUT40RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofG57 licensed authorized representativek <br /> hereby authorre(print name) S l S tli y) 0!� )'P.e' 4S5,f)l i&4— g <br /> to sign this San Joaquin County Well Permit Appaeaton on my behalf. I understand this authorization I_s-valid fo <br /> one 01,year arrd in limited to the work plan dated on the front page of this application. <br /> 211611 <br /> tff(174-0:-0O1 <br />