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MAR-06-2002 13:34 FROM PRECISION SAMPLING TO 12094683433 P.01 <br /> I%ftw ... <br /> Copy <br /> San Joaquin County Environmentai Health iDepartnrent Unit of WIMI PLKertft AP1311 atik+n SvpP®mm f <br /> JOB ADDRESS; PERMIT SF<#: t <br /> LICENSED CONTRACTORS DECLARATION (LqD <br /> I hereby affirm that t am ki ensed ur>der the provisions of Chapter 8(commancin8 wig %uar, 7000)Of OiviSip <br /> 3 of the Susir)ess and Professions Cade and my ficense is in ful(ro=arab of t. <br /> License# � 7 Eviration Date. <br /> Dir �-- t:,arptraccor. / ✓4- ���. n.�, _ter 4 w�j 1:�� H/� .� <br /> Signatsae: Title' CJI S a xQ�c p <br /> Printed name:—6 ✓ ✓� ___w�_ . <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby a ian under ply of perjury one cf"folloyArlg dederations7 (CHr=CK ALL THAT APPLY) <br /> I laws and wit maimmn a ooMfrcate of canpwt to self-insure for workers'comp tion, as provided for by <br /> Section 3704 of the Labor Coder for the perfct", wine of fire work for wtuch this perrnrt iS fsstred- <br /> X I have and wr7t frr&mann rro*ers'GWnpsrrsotioo insurarc e,as required by Section 3704 of She Latzer Cade. <br /> for the pe ormmance of the wWork far whirl:this permit is irss ed- My workers'compensation insurance <br /> carrier and pc ntsr hers tire. / <br /> Carrier �-, . i ✓ � ( Poiiiey Nurnbgr <br /> I certify that in the performance of the work for%Which this permit is issued,i shall not employ any person In <br /> any mamier so as to become subject to dor workers'ccmPensalion laws of Califomia,and a,7rr. ee Mat it 1 <br /> 3fitouitS become sAect to the workers'oompen tion pro*ions of Saction 3700 of the LMX r C06e, I$!tall <br /> fiarthrrtnM comply with those provisions_ <br /> Gate: Q"4 sftnature <br /> Printed Alamo^ 7, <br /> WARNING;FAfLURP-TO SECURE WORKERS°COMPENSATION COVEP.Aa la u MI.AWPt7l„AND SHALL SUKWCT <br /> AN EMPLOYER TO CRIMINAL PENALIIES AND CtYIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (VI00,WQ.),IN AWIT ON TO THE COST Of COMPENSATION,INTEREM7,ATTURNEY'S FEES,AND WMAGEa A5 <br /> PRt7VYDW v-cK iN 3eGiww 37v6 OF THE LABOR CODE. <br /> I, f�*W.-57 Ilcerma autharized repreaenta& ). <br /> harshy authmize(print frame) -1-a .r <br /> ro sign this San Joaquin County Well Permit AppilrWon on my behatif. I unders&nd this authorsz3tion is VaNd Jbr <br /> one(1)your and is I ignited to dee work pian dated on the f oM page of this application. <br /> n <br /> �� <br /> TOTAL P.01 <br />