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06/10;2004 09: 21 2094656773 SPECTRUM EXPLORATION P.96E , 01 <br /> San Joaquin County Environmental Health De artinent Unit IV Well Permit Application Supplement <br /> / 75`O S, EC.So , <br /> JOB ADDRESS: R/1 PERMIT SR*: 5�� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 8 (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#:c� 512268 Expiration Date:_4/30/05_ <br /> Date: 0-w-o¢ CrS r. pectrum Exploration, Inc. <br /> Signature: Title; ,_Operations Manager <br /> Printed name: Brenda Crawford_ _ <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> 1 hereby affirm under penalty of perjury one of the following der_larabons: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-Insure for workers`compensation, as provided for <br /> f 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. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. National Union Fire Insurance Co. Policy Number: 6436303 <br /> I certify that in the performance of the work for which this pen-rift is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of CaMbmia, 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 /> Date: �'�Q Q`f _Signature: <br /> Printed Name: Brenda 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 l'N SECTION 3706 OF THE LABOR CODE. <br /> '��`(��I�THOR ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Bre \14 'rawford,of Spectrum Exploration.Inc._(slgnature +ofC-b7 license <br /> d <br /> �,,authorized reptelsen'tativa), '�t <br /> hereby <br /> �aYuthorize(print name) �� P i lt' I t +A&� (,et fC-rVl <br /> to sign this San Joaquin County Well Permit App)teation on my behalf. I undomtand 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 /> 8-29-081 MI <br /> DCPCTOrn Ttur AiIp It. n nIk, <br />