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09/21/2006 TLE 08;47 FAX @1002 <br /> liLai,ian SIJ�1�.7JOTrt�r1� <br /> Saln.�oaracsin Ccsanly EnvirOrlrrdPnt,rr1 H�alGl� ore parunQnt Unit IV Well Permit <br /> Y/ ✓`•IwRIEIII�' Sh' ; (J C (OLIO <br /> JqB ADDRESS:LL:��.�..�.---_�� <br /> — 70,cy <br /> LICENSED CONTRACTORS DECLARATION (L90 <br /> of d Pro#ess�nsunder the Cud 2ndrmy�llicenee is hn f!I fr�-ce(,7 .11 <br /> led, <br /> girig with erection 7400)fli Division <br /> 3 of the BUsiness an Q t O <br /> License#:� - <br /> CmLra r: <br /> Printed name: <br /> WDRKF--RS'+COMpENSA`f'I DECLARATION <br /> 1 hemby affrrm vnder penal(/of pequry OnLh of the following ciedarahons, <br /> cNECK oral=) <br /> 1't)ev+t and will ai tai as cQrtifi e,for*nsethe e!'fOf���nof th waCk far Wrl �this �t iS�Lsucd- for <br /> pX vection 37 <br /> eqWred by <br /> X—I have•and will maintain w wortsfarwhVchth+s perminsil 15 i�uedr My workerS'�rarrtp-PnsaV0n In uarleLaborc Code, <br /> toe the pertom-Ot <br /> cAnier a �1 <br /> 0 <br /> 40Y nuiri <br /> Policy Number: U <br /> camQr. <br /> IssuO.d,I chap nat employ any person In <br /> 1 certify that In the peR►�[rnunacs the wont far Which this p mt' 'is of Ualifgmia,and mea that if I <br /> any mannBr�O ac tea become subject to ttte work'r-°ro�pi o cif law nn 3700 of the Labor Coda,l shlali <br /> should beCoIM SU4gat to ttw workers'r,ImpQnsa'on p <br /> £o hwit`h 1ComplYWh thvSe provisiun,�- 7 <br /> Date: 3(�c �0o(fl _signatulre- --�— <br /> Prlrltad N.ar11s: IQ ,- r. r� <br /> "WARNING:FAR-URE TO SEOORE WORKERF-'c0MPENSATJ0N COYE:RAG4Er IS LJE�iL.AY OU$ <br /> AL SHALL SI.ISJrO T <br /> REo <br /> VOLLAfts <br /> AN irMPL.PYbR O TIONI o THa COST OF Oa Mf CIVIL <br /> FIN aNVS upi'lnERE�70 r- UND NEY S r-F-ES, IaAMAOSS AS <br /> (S140,000.),IN a <br /> PRvYIUFIa FM'IN SCC'h¢1d 5746 oF.-rHF I.ASoR-BpM. <br /> T4 F�IZA �Qt� VR THAN r,.57',§-lGNIWG PERMIT APPLICAT'ON <br /> 7 _ (sig tum ofC 57 licensed authnrSzed ropreS9rl tiV9), <br /> hero##tIdMirc(pirint rixrrrt}__ —— ecriz:asion as vnftd for <br /> ru s111n t1YEs 5aq.!'raa�1lrl Coun+ Ww11 Pen <br /> APpi-aVor%olt mt:I+uharr. 4 undarxtand titt��ufta <br /> ane lt}year nrld 1r,i-MAOd tQ VIq vvb is pisn dmlev,Qtl uiM 1'.'000 01"ge L"41s�pl.prc�uar.- <br /> Z0 �Jdd 5L91�5E86aZ 5L905E86aZ L0:3T 999Z/ZZ/E9 <br />