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07/17/2007 14:57 <br />07/17/2007 08:33 <br />925313 <br />714950 2 <br />GREGG DRILLING <br />MILLER BROOKS EN <br />San Joaquin County EnviranirmnWI Health Department Uni <br />IV well <br />JOB ADDRESS: 3-f , PERMIT SR#: <br />PAGE 02 <br />PAGE 02 <br />supplement <br />hereby afnrm that 1 am licensed under the provisions of Chapter 9 (oornmencing with Section 7000) of Division <br />3 of the Susineo3 And Professions Cede and my license is in full force and eftect <br />'5 i (c� Expiration Date: ' s i l zoib� <br />License C. � _ p ,. <br />11M <br />Signature, <br />Printed na <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 />by Section 3700 of the Labor Code, for the psrformance of the work for which this permit is issued. <br />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:. r . - -- Policy Numlw: <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' oorttpensetion laws of California, and agree that if I <br />should become sub)act to the workers' compensation prolris' S Section 700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: Signature: <br />Printed <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, ,AND SMALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PFNAI TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAIRS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, iNTIEREST, ATTGRNEY1 FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />hoteby auth®rrtea (pelr t <br />to sign thin San Joagvir1 County Well Permit Application on my behalf. 1 understand this authorization is valid for <br />craaa (1) yaaor and In limitod to the work plan dated oro the front page of this application. <br />8-29.421 Ml <br />HI•IU 29.02-M 1 <br />V21*4 <br />