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0E/09/2006 16:40 2094658773, SPECTRUM EXPLORATION PAGE 02
<br /> i F,ECT UM
<br /> o6/09/20013 14:58 FAX L.' ti �✓
<br /> ,.,a,.,..,.�__eat -...._._... . —li i A p
<br /> ........,., tica,ion piement
<br /> i- San Joaquin County Environmental Heal h�bepar;mrJnit IV WeF'ermiSjJf?
<br /> JV002-- PERMIT SR#:w_ •/��/
<br /> J013 ADDRESS;_......
<br /> ��..__.._.....,._......................,,...,.,_...,._..,.,../..,,,.....,..,.w,...,.�w.�,..,
<br /> I
<br /> LICENSED CONTRACTORS DECLARATION (LCD)
<br /> I ) hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000}of OivrSrgn
<br /> 1 3 of the Business and Professions Code and my license is in full force and effect,
<br /> #: _ 1�. �_ Expiration DOW — -�— 3D-��
<br /> License
<br /> Date; — — __Lp ._ Contractor: 5� :+ .--
<br /> Title,
<br /> :i Signature: _ n i
<br /> Pri ited narne: _
<br /> WORKERS' COMPENSATION DECLARATION l
<br /> I
<br /> I h-:reby affirm under PetIaity of perjury ant- of the following declarations: (CHECK ONE)
<br /> _ a enol will maintain a cr rtifiCate of consent to Self-insure for workers'compensation, as provided for
<br /> I hav
<br /> by Section 3700 of the labor Code, for the performance of thv work for which this permit i$issuab
<br /> 1 ,I have and will maintain workers' compensation insoranoe. 3S required by SectiDn 3700 of the Labor Code,,
<br /> ! f'of the pprforrnance of the work for which this permit is issued. My workers'cornpensatign Insurance
<br /> i carrier and policy numbers are: -i'lf�� f
<br /> MAW-Alt
<br /> LAY11Uh Policy Number;
<br /> Carrier:
<br /> I certify th�lt in the; pc:rrormance of til o ih�for which
<br /> cols Pmpenrsatiotl laws of cal rorI shall ��i and agree that f i to '
<br /> any
<br /> manner so as to become subjectf trio Labor Code, I f I I
<br /> should become 5i=bject to the workers' cort'rpensation provisions of Section 3700 0
<br /> forthwith comply with those provisiortc.
<br /> I F_ ,piration Date: $igr}ature;
<br /> Printed Name: `' 5 i
<br /> V,1AFZN!NG: i'-AIt.URI; T()SECURE OR PENALTIES ANIS OCIVIYI, FINE
<br /> Un TU C7NL•• F-I-IUND EU THOUSANQ DOLL.Af�5U8 1EC'T
<br /> AN EMPR.OYFWr?TO CRIMINAL
<br /> ts. 7017,000.).1N /1Lt)f r10N TC] 1 HE r,US I flF L"OfiIPENSATION,IN'rQRL',Sr,A'TTORNEY'S FEES,AND DAMIaG AS
<br /> I pfZOVIDEU F01`i IN Sf_CTION,70C,Or= TIME, LAL30R COhE,
<br /> AUTHORIZATION FOR OT ER THAN C-57 SIGNING PERIVMIT APPLICATION
<br /> (s,l nature ofC-57 Iictirlsrid UthoriT.[d representative;,
<br /> I'Oreby (authorize (print noriye) f� 1
<br /> to Figr� ihir San Joaquin County Well Permit Application an my hGhalf. I undr:raarld this :authorization i;vnlld for
<br /> 11no(1)year and Ir,limited to thY��+«rk,1Iran (falfld 011 the
<br /> front page of this applic�tiocl.
<br />
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