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04/10/2008 16:42 209465877a PRECISION SAMPLINr, PAGE 01 <br /> ► fS <br /> San Joaquin County E6' ental aith moo 6: Department Unit IV Well Perrttit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> lti.�o�- �� <br /> LICENSED CONT TORS DECLARATION (LCD) <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 P 636387 Expiration Date: 1_L31 /2010 <br /> Date: u-^ Contractor: Precision Sampling, Inc. <br /> Signature: juu Title:_.Location Manager <br /> Printed name: Brenda Crawford <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 certificate of consent to self4risure 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 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 /> CarrierLiberty Mixt_ual Tnsuzancg Policy Number:WC1 W1 07233,9027 <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 Califomia,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: 6/3 0/2 0 0 8 Signature: <br /> Printed Name: Brenda Crawford ` <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES UP TO ONE HUN13RED THOUSAND DOLLARS <br /> ($400,000.),IN ADDIT(ON TO THE COST 01:COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3709 OF THP LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-67 tensed orized representative), <br /> hereby authorize(print name) SA?n ' <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8- k2 EMI <br /> EHD 29.02-W i <br /> 6/22/04 <br />