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THORNTON
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2900 - Site Mitigation Program
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PR0528038
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Last modified
9/26/2019 9:34:59 AM
Creation date
9/26/2019 8:56:52 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0528038
PE
2950
FACILITY_ID
FA0018998
FACILITY_NAME
NCPA LODI ENERGY CENTER
STREET_NUMBER
12751
Direction
N
STREET_NAME
THORNTON
STREET_TYPE
RD
City
LODI
Zip
95242
APN
05513016
CURRENT_STATUS
01
SITE_LOCATION
12751 N THORNTON RD
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: Z./ /V. ;rhi>,ZV7Z7A/ HERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full fort and effect. <br /> / Ilicense#: �J Exp Date: 3i <br /> Date: ( Contractor: C yaII /I <br /> Signature: Title: �f <br /> Print Name: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) 4 <br /> _I have and will maintain a certificate of consent to self-insure for workers'compensation, as ' <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this i <br /> permit is issued. <br /> �i I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' ! <br /> compensation insurance carrier and policy numbers are: G <br /> Carrier: Policy Number: ��b� � <br /> I certify that in the perfo mance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code I shall forthwith comply with those provisions. <br /> Exp. Dater I f 0 Signature: � (l(�� <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Lr (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 1-,-19124.y Z3.z4 MA6 6&5 to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> I <br /> af29102IM1 <br /> EHON011VW7 Y LLPERMITA" <br />
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