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04/18/2008 11:32 2094658773 PRECISION SAMPLING PAGE 01 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: o� C'C> �C'��zl U S�, &!x PERMIT SR#: <br /> Clem e,v�' <br /> (LICENSED CONTRACTORS DECLARATION (LCD) <br /> I herebyaffirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> � <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 636387 Expiration Date:_ 1 /31 / 1 0 <br /> Date; (� 0 1� Contractor: <br /> Precision Sampling, Inc. <br /> Signature: <br /> Title: Location Manl er . <br /> Printed name: B <br /> WORKERS' COMPENSATION DECLARATION <br /> I <br /> 1 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 /> 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'compensation insurance <br /> carrier and polloy numbers are: <br /> CarriergILL Ince_Policy Number:WC1B71072339027 <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 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: 6/3 0/2 0 0 8 Signature: <br /> Printed Mame: 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 DOLLAR-5 <br /> P$ROV DEDFOR SECTION 37 6 OF THE LABOR CO <br /> ,IN DDITION TO THE COST OF ATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. (signature�off+C� <br /> me -6 i <br /> 7 ; ensed authorized representative), <br /> hereby authorize(print na ) `l "" <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization 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!MI <br /> END 29-02•W I <br /> 6/22104 <br />