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05/25/2006 11:17 2094659773 SPECTRUM EXPLORATION PAGE 02 <br /> /V" <br /> San Joaquin County lcnvironmental Health Department Unit IV Well Permit Apnlic`aiti Supplement <br /> JOB ADDRESS: 26 C%, JG 5-W PERMIT SR#: v 0� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commenting with Section 7000)of Division <br /> of the Business and Professions Code and my license is in full force and effect. <br /> License#: 512268 Expiration Date: 04-30-07 <br /> Date: �'25r0 Con dor: S ectrum Eat lobation InC. <br /> Signature: fie: Location Manager <br /> Printed name_ Andy Docker <br /> WORKERS' COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the follow+ng 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 aro: <br /> Carrier: National Union Fire Policy Number: I <br /> naurance ompany <br /> I 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. <br /> Expiration Date_ a4-01 ^raj Signature: <br /> Printed Name: <br /> _R� "lly—D S;kary <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> (i1ab,000.),IN ADDITION TO THE COST OF CpMPENsATION,INTEREST,ATTORNEY-s FEES,AND DAMAGE$AS <br /> PROVIDED FOR IN SECTION 37DO OP THE LABOR CODE. <br /> AUTHORIZATIO FOROTH THAN C-57 SIGNING PERMIT APPLICATION <br /> Aol( (signature oIC-67 licensed authorized representative}, <br /> hereby aut prize(print name) d ( _ 'PRAL/►V. <br /> to sign this San Joaquin County Well Permit Application an my behalf. I 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 /> 9•29.421 MI <br /> 6HD 29-02-00i <br /> 4=4 <br />