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02/02/2004 17:31 FAX 7073744300 Woodward Drilling 131002 <br /> NOV. 3.2004 9:37AM APE*,.,NVIROTECH,INC. 11" NO.077 P.2 <br /> San Joaquin County Environmental Health Deportment Unit IV Well Permit Application supplement <br /> JOB ADDRESS: '514611 F PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> i hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Olvision <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License* Expiration Date: 10-7-31— <br /> I <br /> 7—31— <br /> ! " aD J4 -P Date: r. ri l^f Cd/iA. NTV <br /> Signeturo: <br /> Lam. C wz-�-�— Title• P� <br /> Printed name: t11?A G/ A.1 e,- <br /> WORKERS' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _t have and will maintain a certificate 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 /> •X I have and will maintain wo*em'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; �17"i✓ rip Policy Number: 002 0 2-38- 2-2'6y <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner to as to become subject to the workers'compensation laws of Calffomia.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 /> Expiration Date: 10 �0! —OS Signature:� , <br /> �=�- <br /> Printed Name: l-L)U b 0 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUi3JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDROD THOUSAND DOLLARS <br /> (=100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,A'TTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LA13OR C013E. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPUCA-nON <br /> I <br /> I, d'V C,/ A2 6; lee- ,2 U(sipnature of9G67 licensed authorised representative), <br /> hereby authorize(print nameL , <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> I <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> B-29-02/MI <br /> Ebib 2942.001 , <br /> 6(LT/O4 <br />