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- 04,'e0/2006 06:24 FAX 7148386759- TESTAMERICA DRILLING 002 <br /> Apr. 19. 2406 2:28PM Adv*„.,ed Geohvi ronmeatal ,,� No. 4619 P. ' <br /> San Joaquin County Environmental Health t)epartment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:2 L q( /4 L) PERmrr SR#: <br /> LICENSED CONTRACTORS DECLARATION (L9Q <br /> I hereby affirm that I am licensed under the prWsions of C?Mpter 9(eommendM with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effecL <br /> ucense rf; $I'Tt Y$ Expiration bate: -SC 3 s- / <br /> Date: Contlscor.;si I7y�eweA )s.cc ,,c Ce,•f ��s ����/ r•,t{ lcc..+�i <br /> Signature: Tl#le: O C]� �G 1 k�►r �l�.. <br /> Printed n C,441w. E"'�l dxeedt.41_7� <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby-affirm under penalty of fury one of the following de watioris: (CHECK ONE) <br /> _ l hays and will malntain a cer#tftcate of consent to self-Ptioufre for workers'compensation,as provided for <br /> Eby Section 3700 of"Labor Code,for the performance of the work for which fhis permit b issued. <br /> _�_ <br /> ✓ I ham and Willmaintain workers'Compensation tnsmnce.as raqulmd by Section 3700 of the labor Code, <br /> for the performance of the work for which this permR Is Issued. My workers'compensafion insurance <br /> carrier and policy nufters are: <br /> Carrier. o+A .Pr6A_A 1^et Policy Number: 2 W dV V-AA 7131 <br /> I certify that in the perkwrrwoe of the work for which this permit is issued, I shall not employ any person in <br /> aV mariner so as to become subjeotto the workers'compensatlen laws of California,and agree that if'I <br /> should become aubject to the workers`compensation provisions of Section 3704 of the Labor Code, I shall <br /> fvrtl mhh comply with those provislorts. <br /> Expiration Gate:, i9(- d-6-11 Signature: a' ` <br /> Printed N ." TA�4 /4• e r <br /> WARNING:FAILLIRP-To ZS0UREIN0S'COMPENSATION COVERAGE IS UNLAWFUL,AND S14ALL SlfliuECr <br /> AN 04PLOYER TO CRIRMkAL PENALTIES AND CML i=INEg UP TO ONE HUNDRED T14CUSAND DOLLARS <br /> (6i00,000.�IN ADDITiCN TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR QXWR THAN C-67 SIGNING PERMIT APPLICATION <br /> 11 a I- 5 r slgnature*W-67 licensed auutorbxd represpntathre), <br /> hereby authorize(print dam 1 J <br /> to algin this San Joaquin County Wall Permit Application an my behalf. 1 undemtand tiffs authorlxation is vwltd for <br /> one(1)year and is Nm ted to#w Work ptan dated on the front page of this appikatiion. <br /> a-29-021 mi <br /> er[n 24-oa-0oi <br /> eran4 <br />