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10111/2005 15: 41 7073745677 WOODWARD DRILLING CO PAGE 02102 <br /> UC I .11.20n.'3 2:20PM APEX ENVIRoTECH,INC, N0.693 p.2 <br /> Sen Joaquin County Environmental Health Papartmenii Unit IV Well Permit Application Supplement <br /> JOB ADDRESS_ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (SCD) <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 licenas Is in full force and aftct. <br /> �q i <br /> C.icense t`k � �, O T)7 q _^Expiration Cate: �7, <br /> Date: O Contractor. GJOo p Wajz�o <br /> Signature:, Title: <br /> f P- <br /> Printed name: JN -,0 t f= () 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 cortificate of consent to self-insure for wort ers"compensation,as provided for <br /> �YY by Section 3700 of the Labor Cole,for the performance of the work for which this permit is issued, <br /> -X—NJ have and will maintain workers'compensatlon insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit In issued. My workers'compensetion Insurance <br /> carrier and policy numbers are; <br /> Carrier:,4CT222'3c jEi4A/.IO _"Policy Number,. 60 D a <br /> I certify that In the performance of the work for which this permit is issued, I 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 provislone of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: /� Signature: <br /> Printed Name-_ i:�,a^)z-j N G (,,L)QaD- s1A9,0-- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANP CML FINE,2 UP TO ONE HUNDR9I5 THOUSAND DOLLARS <br /> ($16n,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 0TH R THAN C-57 SIGNING PERMIT APPLICATION <br /> I. (slgneture ofC-57 licensed authorized raprosentstive), <br /> herabyauthorize(pri ame) IK <br /> to clgn this San Joaquln County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is llmitad to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> RED 2042-001 <br /> 6(22(04 <br />