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• S <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License #: 6a0zz7 Exp Date: 11/30/2010 <br /> Date: o6 15 2010 Contractor: Advanced GeoEnvironmental, Inc. <br /> Signature Title: vice President <br /> r <br /> Print Name: Robert E. Marty <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> X I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Travelers Casualty ins. policy Number: UB3338T982 <br /> Co. of America <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10/17/2010 Signature-. _ ek <br /> Print Name: Robert E. Marty <br /> SHALL SUBJECT AN <br /> MPLOYER <br /> WARNING: CRIMINAL PENALTIR S AND CIVIL FINES UP TOTS COVERAGE00,000,IA DIT OIS NTO THE C SDT OF COMPENSATION, TO <br /> INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> to <br /> hereby authorize(print name) <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 8129102111,111 <br /> WELL PERMIT APP <br /> EHD 29-01 1115107 <br />