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05/23/2008 09:09 925313 GREGG DRILLING PAGE 02 <br />05/20/2009 08:24 714960 62 MILLER BROOKS PAGE 0b <br />FJ:OB ADDRESS: <br />San <br />Joaquin Crtcenty Emtironmental Health <br />unit iY Well 1 wmlt Application SUppiemental <br />00 . <br />I hereby aiTirm that I am licensed under the provisions of ChoPWr 9 (commencing with Section Olvision 3 Of the Business and Profasaions Code and my license Is in full force and effect. <br />. a <br />License <br />, - <br />rotor: <br />Contra <br />4� <br />_ Signature:.Title-. <br />I hereby affirm under penalty of perfury one of tbo fallowing declarations: (check one) <br />I have and will maintain a ceridiiFicatle of consent to self -insure for workera' 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 />1 have and will maintain workers' oompensation 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: t <br />re:Carrier:® Cl Policy Number; �,, ►pt? (��� — <br />I caffy that in the performance of the work fbr 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 pr2299Z6��_ <br />t=atp. Daterf%�l Q� Signature, <br />Print Name, tm �MAV - <br />WARNING: FAILURE TO SECURE» vmRKEIW COMPENSATION COVERAGE IS UIULAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIM04AL PENALTIES AND GIgL FINES Up To #$00,000, IN AopMON ro TWE COST OF COI PPRISATION, INTEREST, <br />ATTORNEIPS FEES, ANP DAMAGES AS pRO CF0 FOR IN ®ECT10N 8106 OF NE LABOR CODE. <br />�FCOTHER THAN C-57 SIGNING PERMIT APPLICATION <br />l(signature of C -d7 licensed authorhmd repre8erltathm), <br />hereby authorize (print narrmo) , tO <br />sign tris San Joaquin county Well Permn Application on my WWI!. I understand this authorization iR valid <br />for one year and is Ilmiked to the work plan dated on the front page of this application. <br />a1"MV16111 <br />wrLL MW APP <br />F,mu 28-01 1115ID7 <br />