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08 / 15 / 2007 12 : 55 925313 . J2 GREGG DRILLING PAGE 02 <br /> 08 / 15/ 2007 12 : 07 5306766005 STRATUS NO CALIF PAGE 02 / 02 <br /> Son Joaquin County Erkvirornmefitak KWIM Deperbnent Unit IY well Permit Applieauon Supplement <br /> JOB ADDRESS: b l� , J S� PERMIT $Rik ®: � � Z <br /> LICENSED CONTRACTORS DECLARATIONImo) <br /> 1 hereby aifimt khat I am likonced under the provlsichs of Gheprer 9 (eoMMencins with Sedlon 70M) of prion <br /> 3 of the Busine <br /> ss <br /> and��Fff/Prolasssllon¢ Cade and my license is in full force and effects p <br /> Lleensefr `7 � Pxplmtion Date: J� SCJ <br /> Dao o <br /> signature: /lZ T`iw: Vfri rOL7l + O VIS W' JM 7 <br /> Printed nam <br /> em. <br /> IE <br /> ORRS' COMPENSATnjMM OX CLARAVON <br /> I hereby affirm under penalty of perjury oneaf the following declarations: (CHECK CNE) <br /> 1 have and will maintain a certificate of consent to seliAfnaore for Workers' compensation. 99 prodded for <br /> by Section 3700 of the Labor Cade, for the performance of the wohc for whloh this permtt is issued. <br /> KI have and wi l maintain workers' eempensation Insurance, as nagoired by sieeGan 3700 of ft Labor Code, <br /> for the performance ofthe work far which this pemnt is issued. Nfyworkers' compensation insurance <br /> carfierand pollcy number0 arm n <br /> Carrier y �� ftilcy Number � 07 y� <br /> Lj <br /> I eertlfy that in the performance of the workforwhich this Derma Is Issued, I shall not employ arry person In <br /> *my manner so as to beoorna subject to tha worlmm' cornpensation laws of Calffomiao and agree that 0 I <br /> should become subjeetto the wodkeK' enrnloep tion provisions of SectioDofttre Labor Cade, f shall <br /> forthwith comply with those rovisorm <br /> Expiration pate: +� Slgnaturo <br /> Pdntad Name: C 5s I tg r u7i 'Pia <br /> NfARNWG; FAILURE To 55CURE v0ORVERS' 6DNPSMA11cm CDVERAGE is 1JUL1WFui, AND SHALL su9JEcT <br /> AN EMPLOYER TO GRI K4L PENALTPS ,AND CML FINES UP To ONE HUNORM THOUSAND DOLLARS <br /> 0160wWe-f. IN A=MON TO THE COSI' OF COLI PENSAMN, iNTERGgT, ATTORNEY'S FEES, AND DAMA®ES AS <br /> PROWGE© FORM SECTION 3706 OF THE LABOR CODs;, <br /> A l FO ER THAN CST SIGNING PERMIT APPLICATION <br /> Y, .,^.,� tstgnnwee afCsr Yaenaod authmkzed rRreaentmdre <br /> her96y Otdboflie fprkrt rraknu). Yf' J✓IYJ+�g .2- <br />