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ant By: Gregg Drilling & Testing, In ; 925 313 0302; Dec-12-00 9: 14; Page 3/4 <br /> 925 3130302 •140.016 HF,2,13_14 <br /> DEC.12.2000 10�00RM TKtH s nv��v f'L <br /> 12/09/2000 ej;57 eoy4693saa <br /> _ Zg945B3439 <br /> 4 2001 <br /> s Unit iV Well Parelt Applleatiop Supplermm'A <br /> Fn <br /> aquin County Envlronmental Heafth SeWke ' <br /> Y y S PERMIT <br /> DRESS: ZV'� <br /> LICENSED CONTRACTORS DECLARATION LL W <br /> fFlrtn that I am licensed under the Prov alone of Cheptor 9 (cpm ncrng wjth Section 7000)of Division <br /> usines <br /> s and prolesslom Code and my license k to full lone and erfaot <br /> �'S ? �p ExPlrattm Da18:Contractor: Tmle: <br /> e:name: WORKPRS' COMPENSATION DECLARATION` afflrr under penalty of penury one of the 101bwing declarations: (CHECK ALL THAT APPLY) <br /> X I hegira end W it mahlein a aert'rfioate of consent to self-insure for workers'conn permit <br /> is ea ptrovlded for by <br /> T`Section 3700 of the Labor Code,for the perform once of the work for whlah tills permit is is9uad. <br /> have end w tl melnbin workers'oompensabon insurance,as requ-red by Section 6700 of the Labor Code, <br /> for the performance of the work for wnleh this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are: 4S�00 Z-fi, <br /> Policy Number: <br /> Gamer.��y�' le any arson In <br /> I Certify that in"performance of the worftfor which this permit is Issued, shall not <br /> nd Was Person <br /> If I <br /> any manner 60 ac to become subject to the workers eompencatlon taws f <br /> aSection 8700 of the Labor Code. 1 shallshould h o subject Provisions- <br /> Data,- <br /> m the Workers'compensation Provisions of <br /> forthwith comply <br /> wrth Date:, ra r/ -�n0 _Signature: <br /> Printed Nama: SUBJECT <br /> r t' yyARMNG:FAILURE TO SERF WORKERS'COMPF_N3ATION rOVERA IS UNu►WF11b AND SHALL <br /> AN EMPLOYER f0 CRIMINAL P�NALTIRS AND CML PINES tlr TO ONE ttuNDRED THOUIIANA Ot]L,AMA <br /> PROVIDED IN FOR IN SECTION MON TO 3HF COUT OF Op COMPABOR�KnON�INTHREST,ATTORNEYS tea•AND DAIYIAOE6 AS <br /> G57 rieenaod aulhorhted ropr946ntaNve),hereby <br /> 1, <br /> authorize <br /> ikatlen on my bamalf. 1 understand this auttrortyation is rat"rd icr <br /> to sign this Sen Joaquin County Well Psfmtt App <br /> �w <br /> ,he(1)year and is limned to <br /> work Pian dated on the front page of Mb eppticatlon. <br /> 5-t7do00IYII <br />