Laserfiche WebLink
FEB-07-2002 14:44 FROM PRECISION SAMPLING TO 12094683433 P.02 <br /> R <br /> ft"do"Uia County EhAmnm*ntai Health Vq Unit for Well Permit <br /> ApJt)lir~itiotr su,pplereerrt <br /> JOB ADDRESS. PERMIT �R#: <br /> LICENSF-D CIDNTRAC7ro CECLAF ATIONV LCD <br /> I hereby o firm Ow I am licensed under fhe proViarorm of-rAmpkw 8(Comrnencin vault Section 700)of Division <br /> 3 of tlt Business and Prafessbm CodQ wd my 0M Ise is in full farce and eruct. <br /> License� G 3 S 3 a? tDplratlon Date: 3> 4sa <br /> 53gr1atr#1�. TM.- Z <br /> Printed nar:le: CK e c,n <br /> WORKOW COMPENSATION DECLARATHM <br /> I hereby affirm under penalty of Ixgury one of the followtr,g dwaratlarms; MHECK MJ..,THAT APPLY) <br /> I Its alVIVA Mkftn o tert?Wgte of oa wwd to sed-insure for warkers'compms0m,as provided for by <br /> ^Seofion 3700 of the Labour Code,for ttte perforrrmnce of the work forwhich this permPt is issued. <br /> 1 lbw and will rr OhtWn wr**eTs'compensafon insurance,as required by See0n 3700 of t m Labor Cade, <br /> for M peff0 rra;roe of toe work for vM gZ this paFrWa is i*$sed. My wwtws`Qxrg 000n inselrance <br /> +Carrir3rr arrccl p0lpy numbery ale: i <br /> carrr�r: v J o t Perry NumbW. 1.•.&I "97Z Z 31-? '6�0 <br /> _I certify brat in the perl'bunanoe of fire work far which this permit is issued.I shall not employ any person in <br /> any rnarlm so as to become subject to the workers'compenew ion laws of C.ailforrrin,and aWft that if I <br /> should beco ne subject#to the viftees'compsmatim provkftns of Sactien W00 of the Lsbar Calle, J shall <br /> fbrft*gth comply wah fooso prmnsimm- <br /> Darb ., Sigrwture: <br /> Plow Hdrse: <br /> WARNING:FAILURE To SECURE WORIMRS'OOMMINiSA17D11 COWitME 0 tIMt-A1 r-UL,11W SHALL StJWECT <br /> AM R414JOVER TD C101111MAL PENALTIM AND CML FINES UP TO OffE HUNDRED THOUSAND DOLLARS <br /> t$100JW.� N AtiDt'rM T4 THE COST OF COMPENSAMN,P EIMST,ATrIORNP-rs rEM AND EfMAM AS <br /> P1f{6 VKIED FOR W SECT OM 37M OF THE L"OR COtM. <br /> —ogmaore goeomad } th9dwo fit , <br /> t pti rrt eaettC lr-'err~ z �rt-d„��� �er O 1'cz s T <br /> to sign brie Ben JumWirf Gly Well Permit Apptitaion an my behalf. l anderstand this owdwntaftm is valid for <br /> one(1)WW wed is krfthed to the wwk plan dvW on the*mt pia of tltia appl oallorr,. <br /> 7-?3-a2f 1AI <br /> i <br /> 1 <br /> TOTAL P.02 <br />