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San Joaquin County Environmental Health Department <br />CONTRACTOR AUTHORIZATION FORM <br />JOB ADDRESS: Mile Post 103.09 (UPRR ROW) Near 114 S Industrial Ave PERMfT 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: Geo -Ex Subsurface Exploration <br />License #: 95426 Expiration Date: 7/31/2022 <br />Signature: _� Title: Owner <br />Print Name. Tom Scott <br />Date: C1 k] /Z I <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 />10 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 />p� 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. !�e � t S /� Policy #: Q5390 \ _ Exp. Date: --`t-"_9 12-1 <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 I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Print Name: Tom Scott <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 AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />PERMIT APPLI <br />hereby authorize Maria Ayala <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and I Nnti ted to fh�work plan dateden-the fwnt page of this application. <br />sp.rn a Gsr ua.«o �o+we wawiwm+ <br />