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12/15/2006 09:32 9253130' 2 GREGG DRILLING PAGE 02 <br /> s <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 00",-4, � AMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION L( CD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Busin s and Pr4fessio�s C 8 and my license is in full force andeffect. <br /> SS I(o ri l 1 - - -Og— tic-s� <br /> License#: Expiration Date: 10 — — <br /> Date:L0,-�) 5 Contra or. REGG DRILLING & TESTING INC. <br /> Signature: Title; OPERATIONS MANAGER <br /> Printed name: MARX Wk4N <br /> WORKERS'COMPENSATION.DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have.and wUl 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 /> XX 1 have end will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for theperrormanee of the work for which this permit Is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Canter. SEABR IGHT Policy Number: BB 1 0 6 0 2 61 <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 t <br /> should become subject to the workers'compenset( provisions of Section 37 f the Labor Code, I sha() <br /> forthwith comply with those provisions. <br /> Expiration Date: 8-1 -07 Signature: <br /> Printed Name; MARY WALDEN <br /> WARNING:FAILURE TO SECURE WORKERS`COMPENSATION COVERAGE IS UNLAWFUL..AND SHALT,SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (9100,000.),iN ADDITION TO THE COST-45F COMPENSATION,INTEREST,ATTORNEVS FEES,AND 13AMAGES AS <br /> PROVIDED FOR IN SECTION 8706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 0 N ..57 SIGNING PERMIT APPLICATION. <br /> I, MARY WALDEN -67 license authorized representativa), <br /> hereby authorize(print name) <br /> to sign thio San Joaquin County Well Permit Application on my behalf. I understand this authorl=tlon Is valid for. <br /> 0110(1)year and is limked to the work plan dated on the front page of this application. <br /> 8.29.021•Mi <br /> MM 29.02.001 <br />