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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:3380 NMI TraCyBotfeyard(,oPN21<45"1) PERMIT WP#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name.Malnsmpe Engmanng Labs <br /> License#: 670761 Expiration Date:01/3112022 <br /> Signature:,___?��__e Title: A55,S-1;9,vr A,6�tiFrra <br /> Print Name: Travis Twaddell Date: 07/01/2020 <br /> WORKERS' 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 /> 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: 3o7_2rn-r6 �Ccf"NY POI icy#: P9_?Z]3q/— ZoiExp. Date: l0/01/Zoi.0 <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 law of California,and agree that if <br /> should become subject to workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith ply with those provisions. <br /> Signature: / <br /> Print Name: Travis Twaddell <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> j <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Jy�V11 I ew o o c -e Z ,hereby authorize Travis Twaddell <br /> Name o/CST lJonfeC AVIMIiaC RepeaanMive Vrin1 flame M Auewued Aaeet <br /> to sign this San Joaquin County Well&Boring Permit Application on my behalf.I understand this <br /> authorization is valid for one yea �hd is limited to the work plan dated on the front page of this application. <br /> a t W CST see AumorRee Rep,et I-. <br /> EHD 29-01 B-1-2017 Site Mitigation WeIVBoring Permit Application <br />