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05/16/h20071613:06 9253130? <br /> XUUi l ;j�r'iU ''� Inced GREGG DRILLING <br /> Geo4n�ircnmental <br /> PAGE 02 <br /> 2621 P. <br /> San Joaquin count <br /> Y Environmental Health <br /> JOB RESS; <br /> ADD DePsrtment Unit fV <br /> Wall PB <br /> N n?ari 1l„ rntitA <br /> c� Al 11411 Supplement <br /> ` }7 +aefol PERMIT SR*: <br /> r`,C41t+oaq�0. S fn 1 <br /> LICENSED CONTRACTORS DECLARATION <br /> f hereby affirm that 10M IiCeneed un CLCD} <br /> 3 of the business and Prot der the provisions of <br /> essions Code and Chapter 9(comrrFencin <br /> Licenno# my license is in full force and enc' g with Section 7000 <br /> Cp )of Division <br /> Cate: f� �� Expiratipn Data: 101 :511 <br /> O,� <br /> Contractor' `� <br /> Signature: �^��J <br /> Printed name: Title: <br /> O1�J <br /> WORKERS, co�r�l;�$Arro <br /> I hereby affirm under penal N DECLAMATION <br /> penalty of perjury one of the � <br /> I have and fo.iowrng declarations- <br /> by Section 3 100 of mitthin a certificate Of (CHECK ONE) <br /> Labor consent to self-insure forwork&s,Com <br /> Code for the Performer <br /> 4 1 have and will maintain ce Of the Work for peRSatlon, as proylded for <br /> for fileworkers corn t^fi'�h this permit is s PrQvt <br /> pertorman�of thq work for Pensation insu, nCe as re <br /> carrier and policy numbers are which this Permit is issued.required by Section 37o0 <br /> My workers'Compensationof the Labor Code, <br /> COrrfer: insurance <br /> 1 certifyh Pollcy Humber: l b <br /> t at in the Performance <br /> any Manner so as to of the work for which <br /> I should became subject subject to the workers' this permit is <br /> forthwith comp) bject to the workers' compensation law Issued. I Shall not emplo an <br /> Y with thus C°mPensation provisions of Ser, of California gree person in <br /> e provisions, on 3700 , and a that if 1 <br /> Expiration Date; Of the Labor Code, I shall i <br /> 2/Signature: <br /> Printed <br /> WARNING:FAILURE To sECURE WORKERS-Nanse; <br /> AN EMPLOY �CY -�- <br /> {$100,000 IN <br /> TO CRrMINAL PENALTIES c0MPENSATION CO <br /> }. N ADDITION TO TFila CD '` D CIVIL FI �RACsE IS UNLAWFUL <br /> PROVIDED FOR IN SECTICyN 3708 OF dF COM NES To HUNDREDHO,, AND SHALL SUBJECT <br /> E LABOR CODE. THOU3ANp DOLLgRg <br /> AUTHORIZATION EST ATTORNEY s FEES,AND DAMAGES AS <br /> ATION FoR pTHER THAN C-57$r,GN <br /> ►' i ING PERMIT <br /> APPLICATION <br /> hereby a ut17 <br /> o e{print name) {Signature ofF67licensed out <br /> fsorired rapresentattve) <br /> to sign this San Joaquin � <br /> unry well Perrnit Appiloatlon on m <br /> one{1l year and leis Y benglt, ►undera �Qn�ti� L <br /> limited to the work pfan dated on t Land thig authors r <br /> 8,29-021 MI he front zatfon is valid for <br /> pace of this ePPllcatlon. <br /> l <br /> z�oz-aoi <br /> 41,11- <br />