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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 355 Enterprise Place, Tract/ 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#; <br /> 680227 Expiration Date: 11-30-2007 <br /> Date: �I� <br /> r ,)ntractor: Advanced GeoEnvironmental, Inc. <br /> Signature: , <br /> Title: vice President <br /> Printed name: Robert Marty <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' cop Sensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> X 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. 0 y workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier.• state Compensation Insurance Fund Policy Number: 13 174 74-2 0 05 <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 become 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: 10-01-07 Signature: <br /> Printed Name' Robert Marty <br /> WARNING: FAILURE TO SECURE: ORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> E$NM111MVI4 IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S )EES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION FM OF THE LABOR CODE„ <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> IEsignature ofC-RT licensed authorized representative), <br /> hereby authorize Fprint name) <br /> to sign this San Joaquin County Well Permit Application on my behalf„I understand this authorization is valid for <br /> one Do year and is limited to the work plan dated on the front page of this application, <br /> U-04131 MI <br /> ESD 29-02-001 <br /> 6122104 <br />