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SR0071235
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2900 - Site Mitigation Program
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SR0071235
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Entry Properties
Last modified
11/19/2024 10:19:57 AM
Creation date
9/19/2022 4:29:09 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
BILLING/PERMITS
RECORD_ID
SR0071235
PE
2905
FACILITY_NAME
VALERO CA RETAIL
STREET_NUMBER
153
Direction
E
STREET_NAME
ELEVENTH
STREET_TYPE
ST
City
TRACY
Zip
95376
APN
23336620
ENTERED_DATE
12/29/2014 12:00:00 AM
SITE_LOCATION
153 E ELEVENTH ST
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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SJGOV\tsok
Tags
EHD - Public
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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: (� � E i C (�v ec�S-f, , , I a- tc y 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 <br />Division 3 of the California Business and Professions Code and my license/is in full force and effect. <br />License #: CS % �kS /- Exp Date: <br />Date: �� �/ `7� Contractor: <br />Signature: Title: <br />Print Name: <br />WORKERS' COMPENSATION DECLARATION <br />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: ��!�4 �� ���� �1� Policy Number: ��� �It �03 <br />I certify that in the performance of the work for 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, <br />and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br />the Labor Code, I shall forthwith comply with those provisions. <br />Exp. Date: <'�/�/.� Signature: <br />Print Name: C171-;, P/-( <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />� r <br />hereby authorize (print name) >r r to sign this San Joaquin County Well & Boring Permit <br />Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br />plan dated on the front page of this application. <br />EHD 29-01 05/09/12 WELL PERMIT APP <br />
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