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02/02/2004 17:31 FAX 7073744300 Woodward Drilling Q002 <br /> Nov. 3.2004 9:37AM APEX,,.., � N0.077 P.2VIROTECH,INC. <br /> ;Signature <br /> uin County Environmental Health capertment Unit N Well Permit Application supplement <br /> RESS: a I PERMIT SR#: <br /> AJ <br /> LICENSED CONTRACTORS DECLARATION L( CL <br /> I hereby Business and Professions aunder the Cod and myeianseions f is in grail Torre and eeffec��t.with Section 7000)of Division <br /> Expirotton oats: �•-31- 11 <br /> — 3 —O Contractor. <br /> 0 DD tnJ�A 1.4-i� C'aIU� ASN <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> ensation,an <br /> by section 3700 f the Labor Code.for the performance of the work filloate of consent to self4itsure for or whi�this permit Is issued.ed for <br /> X 1 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; FUA/D Policy Number: 0020238— Za0 <br /> I certify that In the performance of the worts 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 California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,l shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 10 —0!—OS Signature:( ��'�Z' <br /> Printed Names � 'J�-� ^' � LA,)P b 0 c-J Par/2-D <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IB UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> , OR IN 9EON TO THE 370 O TF1@ t„A90R NSATI N.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDEO <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i <br /> I, Cv" G/ AJ G L c vyii�W i4 k (aionatare 0=47 ticanaed authorized representative). <br /> hereby authorize(print name <br /> to sign this Son Joaquin County Well Permit Application on my behaif. 1 understend this authorization Is valid for <br /> one(1)year and Is limrtsd to the work plan dated on the front page of this appllgtiorr. <br /> 84"2/ I <br /> 6a2/04 <br />