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04/18/2008 11: 32 2094658773 PRECISION SAtIPLING P_GE �1 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application supplement <br /> JOB ADDRESS: kit PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#; 6 3 41 A'7 Expiration Date: _ 1 /31 <br /> �j Precision Sampling, Inc. <br /> Date; ( �$ �$ Contractor: <br /> Signature: Title:_ Location Manager <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, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carriersurance_Policy Number:WC1137107.2339027 <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 Name: Brenda Crawford <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. (signature�of/�C�-b7 licensed authorized representative), <br /> hereby authorize(print name) ` - `� "'`r1 <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 J MI <br /> E11D 29-02-WI <br /> 6/22/04 <br />