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06/23/2006 11: 21 209465P 3 SPECTRUM EXPLOSION PAGE 02 San Joaquin County Environmental Health Department Unit IV Well PsrmitApplieation Supplement ,1013 ADDRESS: 1- . A_-�a!';C,-., OS PERMIT SR#: % 7 T LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division ,I of the Business and Professions Code my licanso is in full force and effect. license#: Expiration Date. q-30--6-7 Date= ntractor. Signature: 60CA-T-/.,1J Printed name: R C v a M LSI fEt W�AI 6- PWIuA WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) I have and will maintain a certificate of consent to setf-insure for workers'compensation,as provided for by Section 3700 of the labor Code,for the performance of the work for which this permit is issued. I have and will meintain workes'compensetlon insurance,as required by Section 3700 of the Labor Code, for the performance of the wotk for which this permit is issued. My workers'compensation insurance carrier and policy numbers are: p�tr PA Carrier:NATtaNaL Qmtoj FTtf � CpoF Policy Number. 1�1C cerIN that in the performance of the work for which this permit is issued, I s not emplcy any person in any manner so as to become subject to the workers'compensation laws lifo is, and agree that if I should become subject to the workers'compensation provisions of S n 3700 the labor Code, I shall forthwith txumply with those provisions. Expiration Date: -`iDI-0_) Signature: (�� Printed Name; 7JCJaY-O Vk-146%C WARNING:FAILURE TO SECURE WORKERW COMPENSATION COVERAGE IS UNLA FUL,AND SHALL SUBJECT CN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED OUSAND DOLLARS ;$100,000.),IN AOOITION TO THE CD MPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 O HFLA R CODE. AUT ORI7JITION 0 OTHER HAN C 57 IGNIN PERMIT APPLICATION I, gnature ofC-67 licensed authorized representative), hereby authorize(print name) t A / dop:5bou to sign this San Joaquin County Well Permit 4lication on my behalf. I understand this authorization is valid for one(1)year and is limited to the work plan dated on the front page of this application. 8.29-021 MI j (illn 29.0'_-00!