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08/02/2005 10: 24 9253130302 GREGG DRILLING PAGE 02 <br /> San Joaquin County Environmental Health Department Udit IV Well Permit Application Supplement <br /> JOB ADDRESS: MASCOT AT CENTRAL PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that l am licensed under the provisions of Chapter 9(commencing with Section 7000) of Dlvisicn <br /> 3 of the Business and professions Code and my license is in full force and effect. <br /> Escense 485165 Expiratlon Date: <br /> Date: 08-02-05 n r. GREGG DRILLING & TESTING, INC.; , <br /> I Signature: Title: OPERATIONS MANAGER <br /> Printed narne: CHRISTOPHER PRUNER <br /> WORKERS' COMPENSATION DECLARATION <br /> hereby'affimi under.penalty cf perjuryone of,he rolloWng declarations; <br /> (CH CK ONE) <br /> I have and will maintain a certificate of consent to self-Insure forwcrkers'compensation, as provided for <br /> by Section 3700 of the Labor Cote,far the performance of the worts for which this permit Is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3790 of the Labor Code, <br /> for the performance of the work for which this permit Is;ssued. My workers'compensation insursnce <br /> carrier and policy numbers are: <br /> Carrier: SEA$RIGHT F�oiicyNumber: BB1050261 <br /> I Certify that in the performance cf the work for which this permit is issued, I.shell not employ any person In <br /> any manner so as to become subject to the workers'c;,mpensat!on flaws of California,and agree that if I <br /> should became subject to the workers'.compensation provisions of Section 370G of the Labor Ccde, I shall <br /> Orthvvit,i comply with those provisions. <br /> Expiration Date: 8-1 —0 6 Signature: <br /> Printed Name: C13RISTOPHER PRUNER <br /> WARNING:FAII_UFIE TO SECURE WORKERS'COMPEN9A ON COVERAGE IS UNLAWFUL,AND ShtALL SUEJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UQ TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'$FEES,AND DAMAGES AS <br /> PROVIDED FOR IN sE071ON 3706 OF THE LABOR CODE. <br /> AUTHO ON OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> I, (signature&C-57 licensed authorized representative), <br /> �IC-N ➢ <br /> heresy authorize(print name) I <br /> to sign this San Joaquin Ceunty Well Permit Applicatlon on my behalf. I understand this authorization ie valid for <br /> one(Z)year and 1s limited to trig work plan dated an the front page of this application. <br /> 8-29-021 MI <br /> EFID 2�02.00i <br /> 6l�J4s - <br />