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10/01/2007 14:06 FAX 714939675%..,, TESTAMERICA DRILLING 1a002 <br /> Oct 01 07 03:00p TestAmarica Drilling Corp 916-61jeO5741 p.4 <br /> 1'nrr yes 6649 P-03/03 <br /> San Joaquin County Emrimnrvental Health Department Unit N Well Permit Application Supplement <br /> JOB ADDRESS:,37/ Ems# 11 >L 2aL,rd3.. PERMIT SRS: <br /> LICENSED CONTRACTORS DECLARATIONLj CD) <br /> 1 hereby affft that I am licwnsed under'the provisions of Chaptsr9(commencing with Section 7000)of Division <br /> 3 of alit Business and Pmk!%SiOn$Code and my lic eim is in full tome and effect <br /> Uoerise 4t 91 71-y S Fxpin3fion babe: <br /> faatrr .10- of-d7 Co _��1�..-�yua�J �,ccr.� �,✓ - <br /> alum Title: <br /> PrintednT;a: ,u�n+.a I'�. a�+rea/t►� <br /> c` WORKERS'COMPENSATION DECLARATION <br /> A hereby affirm under pwNWty d perjury one of the folklwing dedardtionx .(CHECK ONP <br /> ✓ 1 bays and wie maintain a ceffeate of consent to seVnsure for workeW compensation,as provided for <br /> by Section 3700 of the Labor Code,for ltte perfannence of the work for which this permit is issued- <br /> have and"I]M iri>ain work&W compensation inSuranoe,ant required by Seetian 3700 of th®labor Code, <br /> for the perforrrtaltce of ft work for which this pe rrnft is issued. My wodwrs'ecralwsstian InsrlranCe <br /> ca Triar and pommy numbers arta: <br /> Cartier. ?Op-je a gQr*w,cn I.JS✓A^.cd PoW Number: Vc- 2L('-88 <br /> i cantfy that In the performance d the wWk far which this pWW is ia9tled, 19'11211 not•mptoy any person In <br /> arty ma nar so as b become subject to the workers'compensation laws of nCaGfari,and agree that If t <br /> *=W becomte 3011 to rite workers;c7artpertsadort Pewlsionsof Section 3700 of the Labor Code.I shall <br /> torthwfth comply vcath emsB provislona <br /> Expiration DRbe: ey-68 — 31endurs: <br /> Printed <br /> WAR)aNG:FAILURE TO SECURE WORKERW COMPENSATION COVERAGE IS UNLAWFUL,AND WALL SUgUECT <br /> AN EMPLOYER TO CRWfKAL PENALTIBB AND C11/111.FINES UP TO ONE tjUNDRED YIIOUSIWD DOLLARS <br /> P K"ILm IN FOOt INASECTION To THE OST OF LA MFF OR CGDE N'HERESY,ATt'ORNEY's PEESn AND DAMAGES AS <br /> AUTHORIZATION FOR OTHEfi THAN C-57 SIGNING PERMIT APPLICATION <br /> /f• '�! r <br /> r- �c.-/Arz�►J o�lcreA'TfT (eignatute afCb?Ilt:ensod authotl7rsd ropreesntative), <br /> hereby sultw ice(p ti nt <br /> to sign this San Joaquin County Weil Permit Application on my befall. 1 understand this sutltort milon Is wUd for <br /> one(t)year and is armeted Im am work plan dated On tits front Page of this appltallon. <br /> 11.22-021 MI <br /> —• TOTAL P.e3 <br />