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01/19/2001 10:30 17149965182 ADV GEOENVIRONMENTAL PAGE 02 <br /> ":13 2094683433 FIFTH FLOORPAGE 02 <br /> " 1 , <br /> San Joaquin County Environmental Health Sorvices,Unit IV Well Permit Application Supplement <br /> ?? ,• DDRESS: 15600 S. Harlan Rd , Lathrop PERMIT SR#.- <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> -e�e'oy affirm that I am licensed under the provislons of Chapter 9(eommpncing with Section 7000)of Division <br /> :'the Business and Professions Code and my license Is In full force and effect- <br /> License#: <br /> ffect- <br /> License#: 680227 Expiration Date; 11/30/01 <br /> ,j ate: 1/19/Ol Contractor: Advanced GeoEnvironmental , Inc . dba <br /> `. . J EnviroProbe president <br /> Signature:__` t�SVWI� �MG/� Tifle: <br /> i <br /> Printed name: Dr. Joshua Oncr <br /> WORKERS' COMPENSATION DECLARATION <br /> Sereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> ) have and will maintain a certificate of consent to self-Insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> X ' gave and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code, <br /> `Yr t"e performance of the work for which this permit is Issued- My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carner: State Comp. Ins. Fund Policy Number. 1317474 <br /> that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> a.ny manner so as to become subject to tha workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 8700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date. 1/19/01 Signature: y1 7� <br /> Printed Name: Dr . Joshua Ongy <br /> WAP.NING: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 /> (SI 00,000.), 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 /> I, _ (slgnature ofG�57 licensed authorized repreaentaOVe), <br /> herebyautharize(print nama) Mr . Trevor Santochi <br /> t.^sigrr this San Joaqurn County Well PermitApplicatiun on my behalf. I understand this authorization is valid for <br /> ons'I)year and is limited to the work plan dated on the front page of thiS application. <br /> 5-17-20001 MI <br />