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Oct 12 06 10: 34a Mitchel- 1 Drilling . <br /> 707-444-9049 P• 1 <br /> Oct 11 2006 2: 15PM Ramagy.,,r�nvironmental , Inc (9161 P• 2 <br /> 3��17t36 <br /> San Joaquin Counter£nvironnhYntsd Health Department Unit IV Well Permit Application Supple"Ont <br /> JOB ADDRESS. L,&7. Jr--. wig p E K AVO., S T o ck Ta f+ PER#A1T SPW <br /> LICENSED CONTRACTORS DECLARATION (L D <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7DO0)of Division <br /> 3 of the Business and Professions Code and my Tice. a Is in full force and effect. <br /> Llcense ft• 6 7 X 6 1 7 Expiration Date:_ G� 3 v 2. 0-6) 7 <br /> Dote:_ 1 12 f d Contractor. M I TL N$LLL. ID 2 i L i-t u 66,QIP . <br /> Title: V <br /> Signature: <br /> Prfnt6d name: o A'Ji- (,Log 6- <br /> WORKERS' <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following deofarations: (CHECK ONE) <br /> I have and will maintain a oertificate of consent to self-iraure forworkers'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 /> I have and will maintain workers'compensation irmranoe,as required by Section 3TOt1 of the Labor Code, <br /> for the performance of the work kw which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers are. <br /> Cattier. Cit W Fv U-)Ut I N 5_ G 0 • Policy Number. 7 S <br /> 1 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 Cafrfamla,and agree that if 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shafl <br /> forthwith compiy with those provisions. <br /> Expiration Date: Signature: -- <br /> Printed Nairne, 2 F�, �=60 _---- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THWSAMD DOLLARS <br /> (=160,800.),IN ADDITION TO THE COST OF COMPEWATWN,INTEREST,AT ORNE1rS FEES,AND DAMAGES AS <br /> PROVWW FOR IN SECTION 3706 OF THE LABOR COLE. <br /> AUTH RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (s4nsture ofCa7licensed authorized representative), <br /> hw*by suthorts&(pr(nt nam&) J'a S E F if P A M A 6-! <br /> to sign this San Joaquin County Wall Permit AppIicatfon on my b*Mlf. I understand this authorbwtlan is valid for <br /> one(1)year and Is fimlted to the wawfr plan dated on tho front page of this awleation. <br /> 8,20-021 M <br /> EKD 24.02-001 <br /> cryo~ <br />