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02/02/2006 17:05 5102374 <br /> PRECISION SAMPLING PAGE 03/04 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: a1-56 CAAZ�� PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 Code and my license is in full force and effect. <br /> License#: O%,2 515 I— Expiration Date: I • 1-3I• VW5 <br /> Date: 2 Z 20D Co Contractor: wr,GI51 �7/KMl�I l kJG , (tJ C�• ___ <br /> Signature Title: DGG Mbd )L� <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for <br /> by 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: LIQ` i k U-(1)Aq-- Policy Number: W ZG ala( 0az 2j-M 0ZC <br /> I certify that In the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to became subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> Expiration Date:_�'�� �° Signature:— ------- -------------- <br /> Printed Name: -------WARNING; FAILURE TO SECURE WORKERS' -------- <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES SUBJECT <br /> UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> fes_ (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) �M 'L <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 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 /> 0-29.02/MI <br /> RHD 29-02-001 <br /> 6/22/04 <br />