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09/19/2001 09 48 7073745577 WOODWARD DRILLING CO PACE 07 <br /> ­"W15/200i 11 48 289-519 2225 OUDESTO A1C PAGE 03 <br /> San Joaquin County i=nvironmental Hoolth Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: t��f� �c.��_ ��uc _ PERMIT 3R#.- <br /> LICENSED <br /> R#:LICENSED CONTRACTORS DECLARATION (Lr <br /> I hereby affirm that I am iaaensed under the proVislons of Chapter 9 (commencing with Section 7000) of Clyision <br /> 3 of the Business and Professions Code and my license Is In fuss force and efrecL <br /> License at# , rt _ ? . Explrstion Date 7- I -&OL __ <br /> 4 D8te; Contractor , _Qa6WA �� LLtNCaw <br /> ' <br /> Title• ��.T7OUS AN-4 <br /> s#pnsflure: � . , � <br /> Printed name., <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the following declarations (CHECK ALL THAI" APPLY) <br /> I have and will me,lntakt a certtficate of Wlisent to self-Insure for workers't:ompensatlon, as provided fuer by <br /> Section 37oo of the Loor Coder, for the performance of the work for which this permit Is issued <br /> I have and will rnaintairt workers'compensation insurance, as required by Section! 3700 of the Labor Cade, <br /> for Ift performance of the worst for wtuch this permit Is Issued My workers' Compensation Insl.crance <br /> carrier and policy numbers are <br /> Carrion: , :67'iATI ^EV A .., -- — _ Perllcy Mumbar. ., <br /> I ceMfyr that in the performance of the work for which this permit is issued, 1 shall not employ any person In <br /> any manner so as to become subject to the workers'eompensastlon laws of Califomla, end ogm that if I <br /> ahoutd beCorne subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shiers <br /> forthwith comply wlth those provisions, <br /> Date. Signature' <br /> Printed Name: , l �' G15, t''✓t .. <br /> WAI IANG FAILURE TO SECURE WORK1rRS'COIrtAENBATION COVER,.AGS 13 UNLAWFUL,AND SMALL SUWECT � <br /> AN EMPLOYER TO CRIMINAL. PENALTIE3 AND CIVIL FINES P TO ONE HUNDRED THOUOAMD DOLLARS <br /> ($100,000),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF TIME LABCR C009. <br /> I, tE/A CaSEJ 30# l licensed authollaisd reprosintative),hereby <br /> a+,tthotlsr t� �J t]tG.iQ S� <br /> to stgn this son Joactuln County Well Pormit Appilcatlon an cry behalf. 1 underabnd this suthorUntion In valid for <br /> oris(1)yrar and is ltnflted to th•work pier+detect on the front per of this spplIcatlon. <br />