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.,,..._ 0v'9/}�r1gC9/21001 0'3. : 40 -...7073745677rOODWARD DRILLING CO <br /> 19 .'1 202 (hr <br /> i San.10aquin county I~rtvironrnentrat Hawalth'SO+' kft, U tit IV Well Pafrm, 1907, <br /> �p�li�st£I�n �isppityrrti�rtt <br /> i <br /> LICENSED CONTRACTORS DECLA TI (LCD) <br /> norei)y alfrrrn that 1 am licensed under the provis ons.of Chaptof S (rommencing vas€tIh SecUon 7O00)of Division <br /> raf±;ie Susine ss and Prv(eS9i0na Code and my t,censa is in U1 rome and esf`fee" <br /> j1_irens�+wi: Exptrstlon Caste: <br /> I I�ste: ot <br /> I rereh)+affirm, under perl0l of penury orae of t`re toilowing oer-borotlons: (CHECK AU T14AT APPLY) <br /> hrxve end wdti malnt to a0iotiftate of consent to self-insure for w0*6rs'cor t$ati0rt.a&provided for by <br /> -d.Se,ctjor. 3700 of the Labor Code, fres the pefforrtiant:a of khv work for wNch U119 pefftt 6s lssue-d- <br /> 1 <br /> t neiv 7 sand e0l-rnntntairt wtol-kors' COrnpensation insurance, As respired way Stctldlt 3700 of the La+bar Cads±, <br /> rar tha pe <br /> gforrnpuxte of the work for which this pormit is i3s��ss�f �.1y t~rorkers' +�ntpsrrstr��ors irstJranr e <br /> carrier and prA;c-y numbers err: <br /> �rrt : _ "IA►71 � ? W _.y__.�__Pauqr�y Nefmt ar� <br /> I r..afti that i!' the Wformanc-v of tate wort for Which tttt:r permit is i5autw, I sKall ri�e�pfoy arty peram in <br /> ._.. ; <br /> i ;p ry manner so as to bWzOrnO aal�act tv the warker�'C0MPSnS8tinrt la*s of Cst}IPnM"-% s¢�cl armee 'Jtat if t <br /> githould b0comer Subject to the woriaers' cornp%ntoUon provlslons of 1840on 3700 of t-.*L211 tr Code, I srlan � <br /> fo hwith warrpply With those ptavislons, <br /> '" signature: . , � �'" _.. ._ ... ....�... - <br /> Date: _ .- - i <br /> Prsnted Name: <br /> 1rV AfiNr; F'Ai1.l1FiI'"CC7 S G�11=t L C7 �4> t 4' 1.Qf«tt� �f isfit]+t L7 F� GS t U �AifVF' t„�+N �iiAi L U8JOCT <br /> J-,MP1.,OYaR TO CPJMINAL pENALTIES AND CIVIL FINES Up J'Ci CNE HUi'JC REV 'EHt7t.€SAM DOLLARS <br /> ��'rr.C��11:C#bR'� ��C'I'tl��t 3�6 G;~'Y`1`I±�LABOR 41]�E COSTOr- s�t�,!!�''t`L�R1="��'. A.iTfrR'�1S1'"'3 r"-`��.!v,,A,fd�i�AMA�"a1"S AS <br /> 1 <br /> �+I► iO,G r T" �`°!„T- _ _...-__�.M (C-57 ticonsivd atrthtvrtx d roPrea*htat ivs), hisretly i <br /> IC <br /> +.. <br /> sl�jr dWz San Jnagufn COWIty Watt Pmvrt,tt u`kppil"Voo on rr:y beoimlf. t unrlsr%tand thisi authorixaktkot is v-aitd for <br /> y*ar end iy limited to th wrnrk»pfan dated on Ow{rant p*%&af'thir vppg.-a3 4r;. ; <br /> • r iZ .0 Mf <br /> dr <br /> r: <br />