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06/03/2008 14:52 92531302' GREGG DRILLING PAGE 02 <br /> 111.� 1-.ri <br /> San Joaquin County Environmental Health Department Unit IV Well Kermit Application Supplement <br /> JOB ADDRESS: 3230 North West Lane, Stockton 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 <br /> �and <br /> J)Professions Code and my license is in full force and effect. JJ <br /> License#' [ll Expiration Date' <br /> Date. (u L7 Con!;"r* GEE1�l r1 +— <br /> Signature: Title: fil. � <br /> Printed name: <br /> WORKERS' COMPE=NSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 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 /> `r 1 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: I Policy Number: 2 0 l j <br /> 0—+01(f <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 3709 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiratioln date: 00,101 <br /> lot <br /> Signature: <br /> Printed Name:VY IIVy <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED'THOUSAND DOLLARS <br /> ($100,400.),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 /> H TIO R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I {signature cfG-�57 licensed authorized reprasentative), <br /> dv— <br /> hereby authorize(print name) Robert E. Marty, Advanced GeoEnvironmental Inc. <br /> to sign this San Joaquin County Well Permit Application on my behalf. I 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 /> 8-2902 1 MI <br /> rHD 29-02-001 <br /> 6123104 <br />