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04/20/2005 15: 37 2094658773 SPECTRUM EXPLORATION PAGE 01 <br /> VVT�J <br /> San Joaquin County (Environmental Health Department Unit IV Well Permit Application Supplement <br /> J013ADDRESS: 40%-KAITE &C L;kMRDP PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> heieby 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#: 512268 Expiration Date: ^4130105 <br /> Datsi: + Contractor: Spectrum Exploration, Inc. <br /> Signature:_ Title: Operations 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 /> 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. My workers' compensation insurance <br /> carrier and policy numbers are <br /> Carrler: _National Union Fire Insurance Co. Policy Number: 6436303 <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 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. C <br /> Expiration Date: 04/01/05 Signature: — <br /> Printed Name: Brenda Crawford <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN iEMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1(0,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PR(IVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> T ORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> 7 <br /> I, [tMnda ,of Spectrum Exploration,Inc.—fsignature ofC-57 licensed authorized representative), <br /> henrbyauthorize(print name) �A'�' LE,�tA 'Q &F EN6E0 <br /> to sign this San Joaquin County Well Permit Applir tion an my behalf. 1 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 /> 8-211-02/MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />