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(08/10/2004 09:21 2094658773 <br /> SPECTRLMf EXPLl7RA7I0N PAGE- <br /> San Joaquin County Environmental Health Departmeft Unit IV Well Permit Application Supplement <br /> JOB ADDRESS' 0500 <br /> /4%AD PERMIT SRM 590P-_ oto rg 2_ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby-afWm that I am licensed under the provlelons 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 A: 512268 Expiration Data:_4130MS <br /> Date: 0—o-0 Co actor._Spectrum Exploration,Inc. <br /> Signature: fU,�f Title:__Operations Manager <br /> Printed name: Brenda Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and WR maintain a cedficate 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 /> _)L 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. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier._National Union Rre Insurance Co. Policy Number. 6436303 <br /> f1 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 sutqect to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 37DO of the Labor Code, I shall <br /> forthwith comply with those provisions, pp <br /> Date' 4 Signature: <br /> Printed Name:_Brands Crawford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ((100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37110 OF THE LABOR CODE. <br /> HORION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> 1, Bre rd,of Spectrum Exploration,Incn._(elgnature/ofC�37 licensed aut1 mixed repl-maenta0ve), <br /> he authorize tname �� 1�1' OF ltl.fJ/id0P_ &Oh Yi d ) id <br /> reby (Orin ) Ld�� <br /> to sign this ban Joaquln County Well Permit Applrcatien on my behalf. I understand this authorisation Is valid for <br /> one(1)year arta to limited to the work plan dated on the front page of this application. <br /> 9-2"21 All <br /> RECEIVED TIME AUG. 10. 9: 12AM <br />