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04/10/2008 16:42 209465877P PRECISION SAMPLING_ PAGE 01 <br /> 49 Ito 3�-�1J33 <br /> JAtAl <br /> FJOB <br /> Joaquin County En ' ental alth Department Unit IV Well Permit Application Supplement <br /> ADDRESS: <br /> A/P-ERRMIT SR#: <br /> AJ. <br /> LICENSED CONTRACTORS 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 /> Licensed 63'r6''387 Q Expiration Date: 1 /31 /2010 _ <br /> Date: Contractor. Precision Sampling, Inc. <br /> Signature: Title: Location Manager <br /> Printed name: Brerlda C <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 self-insure 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 /> g I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, i <br /> for the performance of the work for which this permit is issued. My workers'oompensation insurance <br /> carrier and policy numbers are: <br /> Carrleriiberty Mutual Insurance Policy Number WC1B71072339027 <br /> I certlfy 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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 6/30/2008 Signature: Q� <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 HUNDRED THOUSAND DOLLARS <br /> ($100,000,), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTH>=R THAN C-57 SIGNING PERMIT APPLICATION <br /> `A' (signature'fC-67 ycen i rued rapreser>�ti4e), ' <br /> hereby authorize(print name a �CfY( Ail 116 0 <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorhation is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8.29.02 I MI <br /> tHD 29-02-001 <br /> c�22i0a <br />