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02/013/2007 16:10 707822 WEEKS DRILLING <br /> PAGE 03 <br /> San Joaquin t:aunty Envtronm4ntsl Health peparfrnent fink IV VNel1 PermitA Readen eu <br /> i) alpP PPtament <br /> JOJOBAOdF;ES3 4 5 , ��PERMIT SR*: <br /> LICENSED CONTRACTORS DECLARATION CD <br /> 1 hareby a(fmn that 1 am lioensesl un Wt the provisions of Chapter g <br /> 3 dFthe Duelrvega mid Prof (caromencinp with Setalon 7000)of bN bier <br /> esslon8 Code and my IiCensp I9 in full farce and effect. <br /> ncin <br /> Llcenes it: 76 Lv ` <br /> iratlon Date•�f3Q/0 W- ' <br /> Data: A.1610 z_._ contractor: P /^ <br /> f'- <br /> -t----.•---.., Tme: LSO <br /> Pdrftd naR : /Q <br /> WORKERS' COMPENSATION DECLARATION <br /> I <br /> I h@mby affirm under penalty of peljury onO of the fallowing dederaticns (CHECK ONE) <br /> I naive arm vole rrmlmain a oeerbii"of COrSent to S@Wrlsure for worktrs'compensation,as provided Tor <br /> by section mo of tho Labor Code,for the performance of the work for which this Pe1mR is issuep. <br /> I have and welt maintain workmm'compomatgn ihaurance,as required by SeClon$706 of the Labor Code, <br /> for the performance of the work for wilit:h thls permit is issued. My workers,compensation insurance <br /> carrier and ponny manbere arra; <br /> Carnet"__z Pn r+7-F� Pellcy Number. <br /> I certify that in the parmrmance of trip work forvdlictt thls permit it ensued, t$hall not employ any person In <br /> any manner So as to become subject to the workA"'0omponsatlon laws of Califpmla,and agree that If I <br /> sheale become subject to the workers'compensation Pravrelons of Section 3700 of the Labor Godo,I shall <br /> farthwah comply whh those pto;nglona. <br /> �plratlon eater: df /Q Signatarr <br /> Printed Name: <br /> WARNING:FAILURE TO SEOURE WORKERS'GOMPERSATION COVERAGE 13 UNLAWFUL,AND SHALL SUSiECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FIN&e UP To ONE HUNDRED THOURAND Dol- S <br /> (4100,4011,IN AOI7r M 70 THE COST OI COMPENSATION,IRMRWT,ATTORNEY'S FEES,AND DAMAGE?$AS <br /> PROVIDRD FOR IN l,"ON 3706 OF Tri;LABioR e=p_ <br /> AUTHORIZATION FOR G7NERTHAN C-57 SIGNING PERMIT APPLICATION <br /> Ir—�«.C,�T�--�!._a�/cSb� ..,r,(;'I�n°tum nrC-671ic4rAmed authorlaed l'1pecRQRMfIVtil, <br /> hOMby ODUM izo(prtnt nargo) <br /> to sign this Salt Joaquin County Wap PWMk AppliCatlon an my hebplf, I understand this author z7tion�g valid for <br /> One(t)year and IS limited to the work plan dated an the front page of this applraal 0m. <br /> 4«25.114 f MI <br /> 611D29-02.001 <br /> 6flLOM1 <br />