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01/14/2008 17:14 209465x' ' SPECTRUM EXPLORA <br /> PAGE 01 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applicatlon Supplement <br /> J013 ADDRESS: d 111 � 4fe47ERMIT SR#: 053 315 <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#: 636387 Expiration Date: 1 /31 /2010 <br /> Date:— Contractor_ Precision Sampling, Inc. <br /> Signature: Title: Location Manager <br /> Printed name: Brenda Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I 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 worts for which this permit is issued, My workers'compensation insurance <br /> Carrier and policy numbers are: <br /> CarrierLibext=v Mutual Insurance Policy Number WC1B71072339027 <br /> 1 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 rf 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 /> Explration Date; 6/3 0/2 0 0 8 Signature: <br /> �l <br /> Printed Name: Brenda Crawford L � <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 ADDrrION 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 /> (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) I` nAA , <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 /> 6,-29-021 MI <br /> El1D 29.02.OD I <br /> 6,122/04 <br />