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' -.pr ,c.—_ s.a.,,rs war. ,- ,. , az ..:j,;t:3[;;. ger—'",e—a;.-Fy.-F . +•,�: <br /> 01/27/2003 MON 11:51 FAI Me",54356 <br /> FROMwest [iaznlat � .. . . . 9062/002 <br /> ' FAX NO. 19155 Jan.' 27 3'12:42F M P1 <br /> r <br /> 9lty/2QlRi €13:31 .03d6tl���i33 <br /> FIFTH r-I.f3dr,., PACE [14 <br /> I <br /> ' San Joaquin Coup Environ." _ = <br /> hr mtJfttol Health Services,U it IV well Pd if 4ppi C-4;jan supply neem <br /> JOB ADDRESS, :a1i►t�acc S bavpERM1 SR#:�D Z�6I.3 <br /> ZaOs IKr2aN., A�. � l: I <br /> LICENSED CONTaRACTORS D CLARA ION L( CD <br /> �. e <br /> f <br /> I herebyaffirm t l <br /> hat am licensed under the pr4vig[orls of C:hapf r =comrne ing with SocE[oai 7�4}of Division <br /> 3 of the Rualness arld professions Code and my license ila in fut force aand'e L <br /> s <br /> Lxpiretion te, 3I- o.t <br /> Date: D/.: -7-O3, Contract= . ! �W. . .. <br /> zl <br /> Zl�1 t�li.l�L�r.l <br /> Signature- f�j', .. d s. <br /> Id <br /> Printed natari c"Vzk <br /> V5 <br /> WORKERS' <br /> WORKERS'COMPENSAMON DEC1_ARA ipjq <br /> I hotarby astir n under pwalty of perjury one of the t6lowing do'claralior <br /> s; {Cf I CK ALL THAT AppLyy <br /> hava and wlll maintain a certlfirata3 of ennsent to self-irm &sr wcrk�ars' mpensation,as Fsroi-Adod for by <br /> * Ihan VOO of the Labor Coda,for the perforn'Ance of the work for whja} lhls pairnit is issued_ <br /> and will maintain workers' <br /> corrapensatiott inaturane&. requirr:d by 4ortion 3704 of Itis Labor Codti, <br /> ,t• T for the porformance of the work for vuWh ttiia parinit is issue .'My work R3 'thIMP8 5ation insurance'. <br /> carrlar-and policy numbers are: <br /> Gaeslai: L-4 <br /> _Policy Numbar. ZL d VtP Lj_`l l_ <br /> �, _�.f'eertily that in the performance of 010 work for whtrh th[r,por it is issued,V shall riot OMPID <br /> y doy person in <br /> any manner so as to bewma�asutr�eM icy tyle workers'cotttperigation laws a Caldornis,and a-ull-i I <br /> should bocomo Subject to the workers'o mt <br /> •• pEw'asation provisions of Sectio 370()nt t i'Gude, l shall <br /> forihwlih comply with those provisions. <br /> oats, Signature, <br /> ;: 7" <br /> Priaittad Name _� tN-rt' j✓�� -Z' <br /> 'r -- <br /> WARIONG:FMURE TO SECURE WoMRS,C0Wffk3An0N Col FEFZAOF IS ll LAtIVFU4 ANI1 S11AL! 5llii.iF,CY <br /> AN EMPtOYF.R TO CRIMINAL PENAL'fiE5 I=FiNgS iffy TO NE HUNiD� D THOusAt4a DOLLARS <br /> {>):1t>tR,tltlp.},IN AbOrMN'TO THE CO CGMpENSATION,INTEREST.ATT'OR EY'S FEES.AND DAMAGFS AS <br /> PROVIDED F(W IN SECT10N S7 E <br /> THE LABOR CODf <br /> ofC-V7(i n"d acthoritecf reprerantativs), <br /> a itsroby audio"(print n 9} A D OIt,( JFid �/-A-tJ a cp z <br /> to 616n tfils Sen J08quln County Well Permit Application on my}wha}, t undlers this autha or <br /> rlxatiari IS valid for • <br /> Ny one(1)year rsnd is lin lend to tba work plan detad an the front pugs thla'abppilca on- <br /> 5-1 7.20001 Ml <br />