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2900 - Site Mitigation Program
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PR0508222
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Last modified
3/6/2020 9:43:08 AM
Creation date
3/6/2020 9:28:51 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0508222
PE
2950
FACILITY_ID
FA0007999
FACILITY_NAME
BEACON STATION #492
STREET_NUMBER
470
Direction
N
STREET_NAME
MAIN
STREET_TYPE
ST
City
MANTECA
Zip
95336
APN
22307101
CURRENT_STATUS
01
SITE_LOCATION
470 N MAIN ST
P_LOCATION
04
P_DISTRICT
003
QC Status
Approved
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SJGOV\sballwahn
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EHD - Public
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01-25-2000 02:32PM FROM TO 1916E539297 P.02 <br /> vow, <br /> San Joaquin County Environmental Health Servicesi Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: '1-10 ,t*k A4ANTc-e,* 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#;_ �90 P44 Z Expiration Date: S'3/ - ZOoc7 <br /> Date: oo Contractor. Z5111,4ssecl,4 7Z-S <br /> Signature: Title: F AWev+ A'L wxevgi� <br /> Printed name: J*,-NJorJ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> —I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> 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 /> Carrier. f,-1ee"o"'7-.�ivswnA-44 C'D^o Policy Number: �✓/✓c�0 �7y�.'�'3c�.Z <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 /> Date: / 2'S"c"� Signature: Lv <br /> Printed Name: 6-75oK-,s � <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 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 /> l' (C-57 licensed authorized representative), hereby <br /> authorize <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 />
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