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09/06/2007 14:53 2094658773. SPECTRUM EXPLORATION PAGE 02 <br /> V we <br /> ent Unit lV well Permit Applicativn Supplement <br /> 7JOBADIDWIESS---=—M� <br /> n County�nvl�nmental Health Departm <br /> PERMIT 5R#: r <br /> C or 950ty <br /> LICENSED CONTRACTORS DECLARATION (LCD] <br /> I hereby affirm that I am licensed under"Provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and professions Code and my license is In full form and effect• <br /> Expiration Date:_ 4-3 0_4 <br /> License* <br /> Dale: C1-to-0-1 GontmcDor S estrum Ex cation.,Inc. <br /> Title. Lavation Mana ez <br /> Signa <br /> Printed name: Brenda Cra��orE1 <br /> 1NORKFRS'COMPENSATION DECLARATION <br /> I hereby affirm under penatty of perjury one of the following dedarations: <br /> 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 worktar which this permit is issued. <br /> nsetion insurance,as required by Section 3700 of the Labor Code, <br /> X I have and will malritain workers comps permit is issued. My workers! compensation insurance <br /> for the performance of the work for which this <br /> carrier and policy tubers are: WC 159 3164 <br /> 143tiorial Union Fire �. policy Number. <br /> Carrier. <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 d I <br /> on provisions of Section 3700 of the Labor Code, I shall <br /> should become subject to the workers'COMPensati <br /> forthwith comiply with those provisions_ <br /> Expiration Date:' 4...1-08_Sign <br /> ature' <br /> Printed Name: 8 da Crawford <br /> CT <br /> WARNING:FAILURE TO IV4APSECURE PENALTIES <br /> RS'COIV11= SA-n0N COVERAGE is FINES UP To ONE HUNDRED w U�SMO DOLLARSUB.fE <br /> AN EMKOVER TO CRIMINAL PENALTIES AND CML AS <br /> ($100,000.).IN ADDM N TO HE OF THE LABOR ODE, <br /> DN.INTEREST,ATTORNE1r'S FEES,ANo DAMAGES <br /> COST OF COMPENSATI <br /> PROVIDED FOR IN sE <br /> AUTHORIZATION FOR OTHER THAN C.67 SIGNING PERMIT APPLICATION <br /> wjnature 01C-B7 licensed aethorbed representative), /1 <br /> hereby authorize{print name} <br /> to sign this San Joaquin County Well Permit Application ori lay behalf. 1 undemtand this authorization is valid for <br /> one(1)year and is limit¢d to the work.Plan dated on the front page of this application. <br /> 8-29-021 ARI <br /> rxn <br />