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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 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 />680227 11-30-2007 License #: Expiration Date: <br />Date: <br />Signature: <br />Printed name: <br /> <br />(sintractor: Advanced GeoEnvironmental, Inc. <br /> <br />Title: Vice President <br />Robert Marty <br /> <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 cop sensation, 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. 0 y workers' compensation insurance <br />carrier and policy numbers are: <br />State Compensation Insurance Fund • 1317474-2005 <br />Carrier Policy Number: <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 I <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 />10-01-07 <br />Expiration Date: Signature: <br />Printed Name: Robert Marty <br />WARNING: FAILURE TO SECURE: ORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />E$/e1vIVIMVTV1), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S ) EES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION PTNB OF THE LABOR CODE, <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Eignature ofC-RT licensed authorized representative), <br />hereby authorize Forint name) <br />to sign this San Joaquin County Well Permit Application on my behalf,I understand this authorization is valid for <br />one BsI) year and is limited to the work plan dated on the front page of this application, <br />U-03-ND/ MI <br />EHD 29-02-001 <br />6/22/04