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Jul 16 01 03:00p Spectrum Exp. 209-465-8773 p. <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS:_J;3?J��(1Ad hlWW- ('qy)e--- PERMIT SR##: <br />�Q45.5 S-i'Recf Ke) y Cans--�,; I� <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 />License#: C57# 512268 <br />Date: 7 <br />Signature: <br />Expiration Date: 04/30/2003 <br />Contractor: Spectrum Exploration, Inc <br />Printed name: Brenda) Crawford <br />TiHe:_Operations Manager <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />—1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />XX_ 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. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: American Motorist <br />Policy Number: 3BG03575800 <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 prov ions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: 1 f to I D Signature: <br />Printed Name: Brenda C wford <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEYS FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />' or. <br />Brenda Crawford of Spectrum Expl(signature <br />1ofC-57 licensed authorized representative), <br />hereby authorize (print name) U 1 K,4 � A. i;:1SQt `�'I'1 WQ � A-16 H S SOf✓!'a It � <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />5-17-2000 / MI <br />