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02/02/2004 17:31 FAX 7073744300 lYoodward Drilling 0 002 <br /> NOV. 3.2004 9:37AM —'rX ENVIROTECH,INC. NO.077 P.2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: a 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: Expiration Date:740-7-31` <br /> Oats: L "0 3 -O Contractor._ni"0oD L44" t Lir C.vM. "`f e -Py C. <br /> F <br /> Signature:: -�- rale• P2 F3 �F�J" — <br /> Printed nameo N C- ," ' O n <br /> WORKERS' COMPENSATiON DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certlflcate of consent to self4risure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Cade,for the performance of the work for which this permit Is issued. <br /> 1 have and will maintain wor{cena'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 /> canter and policy numbers are: <br /> Carrier. r' Policy Number: 00 2 0 Z3 8- Za0 <br /> 1 certify that to the performance of the work for which this permit is Issued, (shall not employ any person in <br /> any manner so 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,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: /0 -01-OS signature: <br /> Printed Name: l�U o 0 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 16 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRSO 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 THB LA13OR CODE. <br /> AUTHORIZATION FOR OTS THAN C-57 SIGNING PERMIT APPLICATION <br /> 14kY,)D(O�1rq P, (signature ofC-67 licensed authorized reprsaentadve), <br /> hervby authorize(print name 9!V Vl © C <br /> to sign this San Joaquin County Woll 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 appilptlton. <br /> 8-29-02!PAI <br /> Elm 2942.001 <br /> 6aVO4 <br />