Laserfiche WebLink
MAY-2-2004 03:29A FROM:ALL WELL ABANDONMENT 1(530(644-1439 TO:12094671118 P.2 <br /> May. 12, loud 2:56VM Advanced tie0tnvironmenlal IND. Llyl r. ) <br /> r_.,-,ny, r,,..l—^ntnt"—i+h nrnnr+mnnt Unit IV Woll Pormit ADDIle2tion supplement <br /> JOB ADDRESS: 3401 Wel,rton Road PERMIT SR#: <br /> I <br /> I.ir_GNCGn r.nNTRACTnRS DECLARATION (LCDI <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 0 of the Duainozo and Profcaolona Coda and my licence is in full forgo and offoet <br /> License# 35 Expiration Date: <br /> Date: Contract All <br /> Q, <br /> t <br /> Slanatur _ �~ --- Title: <br /> PrintedTrdfrr+r.-- r'7` C -- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for <br /> qy Zyo , on 1,00 of J,�I atvv f;, ,-. f-,- n—I,w-r.....--c ft ur tits w:.l'n iu- .-,-w..iL O.o-uo..��,..r•v.wv.'.. <br /> I have and will maintain workers'compensation Insurance,as requirea Ay aecttvn oiuu or Lne t-tuor ucruo, <br /> Tor the PHIMIFTIkIflUe UI III(VVUlK ful WHILdl Milo Lmnnit Io l— J. h1J ...•.l—WI.-,a.n,pv n.wt:.r+;-,..ewe-.. <br /> carriek and poiiGy numbem 3Le' <br /> Clurrter C Policy-Numbdec <br /> G@ I AT6WUT-K fvl wnl%aI iiuo pngilt to iawwJ, <br /> any manner so as to bocomo cubioc!in tlta werk-am'mmw <br /> fnmafion laws of Califnrnia.alid aoree that if I <br /> shni,IN har�nma w1Nr-,-t In thn woricerr,'comnengarion Drovislonti of Suutlufl Z700 ul liln t-a"r U"O, I sn*I <br /> forthwith rmmniv with thnsa Orovision3. l� <br /> Expiration Date: /tel Ilyi� Signature: ------------- <br /> Printed Name: <br /> LAIAMIMIrr.CAII I Iva Tn PrI IRR WARWFRS'Ct')MPENRATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> rc1+ALTleo Af 0 CIVIL-r114CO up-To 00112 f-IU+IonaD TL17Uawr.In Ile\l , n.,.c <br /> VV,VOb,fi In AClOI11Q r+T0 7,1{-{iV6l VY •.v1Y,r.r.alt-ivr.,--v----- .. �•-•_� -. _._�-_J....�a�c r.0 <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUT,KOR14ATION F OTf7ER Ti"AIV t.-57`�tC3r•11fVG�PCRiYfIT ArPPt.l�# i3. <br /> l / (algnature ofC-57 licensed authorized representative), <br /> hotoby autharixv(p.tint name) T anrpn r•1rr�ir331Yi - <br /> to.aeon min Can Jaenuin oountx well Pormit Application on my b.4rnlf. I undera-;:z!thea"ilthnri2atInn Is valid for <br /> one(1)year and is limited to the work plan dared on the front page of this appilcation. <br /> 8.29-021 MI <br /> EHD 29-02-001 <br /> 5/22104 <br />