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09/05/2002 14: 53 19166385611 CASCADE DRILLING INC PAGE 03 <br /> 09/05/203. 14:35 209-57!125 MODESTO ATC PAGE 03 <br /> low <br /> San Joaquin County Environmental HooNh Services,Unit IV Well Permit Appilostlen Supplement <br /> J08 ADDREss: SA . PERMIT SRN: <br /> Si-oC V'AV)/ CA <br /> LICENSED CONTRACTORS DECLARATION O <br /> I hereby alfiam that 1 sin licensed Under the previsions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code end my Hoose is in full fate end effoot• <br /> License aF -7 I -7 5- I Expiration fDate; <br /> Dete: S—o eonteao. �.CL S C D 1-i\ t. Y-No <br /> tlligneturo: Title• ��tf aTiO <br /> Printed nente: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby amrm Under Donelty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I hew and will maintain•eertBkaq of consent lo 969-Insure for workers"eomponsafbn. ea provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for whom this permit Is iffy" <br /> I have ens will maintain wenters'c4itnwsstbn insurance,M required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permil is issuetl. Way wgrkera' compOnaatwn Insurenoe <br /> carver and policyVnumbers are: <br /> Carrier: A l as Ta N a-h an a I Polity Number, D E VS 3 015 <br /> 31 <br /> _I certify that in the Warrnonce of the work for Which this permit Is Issued, I shell not e17100Y env peraor In <br /> any manner so es to be0ome subjocl to the workers'compensation Is"Of California."ogres that y I <br /> should become subject to the workers'cvmpensoon provision of SeoNon 3700 aP tMr Labor Code,I than <br /> forthawith comply wwiitth�those provisions �I <br /> Data: I- S- � P Signature:_ 'r` 7 - <br /> PrlMed Name: rG.- C�� kCk A"N 0 rN ._. <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVIERADE III UNLAWFUL,AND SMALL SVWICT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE MUNDRED THOUSAND pOLLARs <br /> (iii 00,000.),iN ADD"N TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S FEES.AND DAMAGES A8 <br /> ROVIAEO FOR INN SECTION""OF THE LAMM COOS. <br /> I, V t.r t, 4 kin, p M a✓N _(c�Sf bcene"aanherlpd Npeeenl•Uwl.hw"y <br /> "Win- <br /> to sign this San Joaquin County Wip Perfon Appllcetlon on my adf, I anderetend MIs ouM9flob"t Is vadat for <br /> one(t)year and Is IirnRd to Me work Plain on <br /> n dated an Me front peso of 1111114 OPPIICIOOA, <br /> a.ifd000!Mt <br />