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Y <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 661 E ;a"` PERMIT SR#: S6 el�)l <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#: 68022' Expiration Date: ! 1- 30 -y Q <br /> Date: r',)ntractor: Advanced GeoEnvironmental, Inc. <br /> Vice President <br /> Signature: _ Title: ;it <br /> Printed name: Robert Marty <br /> WORKERS' COMPENSATION DECLARATION <br /> rid <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' cop Sensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> X 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. 0 y workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: state Compensation Insurance Fund Policy Number: 1317474 <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 if 1 <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. — / t Z <br /> Expiration Date: l(� I�ITSignature: /+ r ' <br /> Printed Name: Robert Marty <br /> WARNING: FAILURE TO SECURE: ORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> E$M"MuIU IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S )EES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION PTM30F THE LABOR CODE„ <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Fsignature ofC-RT licensed authorized representative), <br /> hereby authorize Iprint name) <br /> to sign this San Joaquin County Well Permit Application on my behalf„I understand this authorization is valid for <br /> one BN year and is limited to the work plan dated on the front page of this application„ <br /> U-C9-M3/MI <br /> EHD 29-02-001 <br /> 6nvna <br />