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81Lt L4-zUU( MON U2: 18 PM GEOMATRIX CONSULTANTS FAX NO 559 264 7431 P. 03 <br /> 0 • <br /> San Joaquin County Environmental Health Department unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 2801 W. Aw, � dbda f->m CA 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License* 636387 Expiration Date: 1/31/08 <br /> Date: 9/29/07 Contractor. Precision Sampling, Inc. <br /> Signature: Title: cA gales Manager <br /> Printed name: s'ric cerat zlan <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (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 work for which this permit is issued. <br /> x I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Liberty Mutual Policy Number: WC11371072339027 <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 1 <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 6/30/0$ Signature: <br /> Printed Name: Eric Deratzian <br /> WARNING: FAILURE TO SECURE WORKERS' ON COVERAGE IS UNLAWFUL,AND SHALL <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND C VIL NINES UBJECT <br /> UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,), <br /> IN ADDITION TO THE. O THE COMPENSATION,OR INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> DEFOR SECTION 37 6 <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8.29-02/MI <br /> LHll 29.02.001 <br /> Fnilna <br />