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FRO+Meson' ntSon:clnternational <br />133/31/2604 09:12 9166510430 <br />FAX NO. :5306682429 Mar. 31 2004 09:45AN P3 <br />SECOR PACE 02/32 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: ORMIT SR#: <br />San Joaquin County Environmental Health Services, Unit tv Well Permit Application Supplement <br />JOB ADDRE G,l �a7�'arR v,rr �'Rzwr'r - <br />I he eby affirm that I ai <br />� � t�: �MIMYn 7000) of Divisio <br />3 of he Business and o i ense is in ul orce an effect. <br />Lice 4**e y af`irrn that 1 am <br />3 of the Susiness and P <br />[] <br />i <br />Sigr <br />Prin <br />na <br />nsed under the provisi@ppipAj4NT* . (commencing with Section 7000) of Division <br />ssions Code NnTm—y-111conse is In full forde an . <br />Printed name: t ,J� � ,�„ �SAYI CLARATION <br />I her by affirm under penalty of 13WORKgR61' I00f6MlWMNr8tMLAF0W0K ALL THAT APPLY) <br />i— titerfri�il� ,1iFi���„bot'tMdWirta�tl�el�oatt�osk��tlKp�4at5fltbP►?}hied for b <br />ectio 700 of the Labor Code, for the performance of the work for which this permit is issued. <br />have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />— I have d## i� it j��{�ado�r� rpfripetha li itt9101t�,d7C) vy@ g��igt )gi�+}rn <br />041`49- Labor Code <br />r the performance of the work for which this permit is issued. My workers' compensatign insurance <br />arried aad�auliot�n,dllmftgta;lramrkers' compensation insurance, as required by Section 3700 of Ie L'9bor cods, <br />for the performance of the work for which this permit is issued. My workers' Compensation insurance <br />C rrier:cArrier and policy numbers ars: Policy Number: <br />p r:. <br />— I ceriRgRA�' r�-fer�ie� t�y�y �� i �s i p o y --Person in <br />ny manner GGs,Qas to beco e sub ectft6thevr(co{u i� (c9fICS��fRriBt� �sidr4fih <br />fhs� 6REIR C M '8 Y�4om,�s� 3 a �i aA ref �°8f s Rfl ; t� iF Shall <br />o t`f�i,Rraers' compensatlon provisions of Section 3700 of the Labor Code, I shall <br />Date fbrthwith comply with thos . rovisions. <br />mature: <br />Data; ( % Signature: <br />rin eTName- <br />Printed Name: <br />WARING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />ANE i In�d'PA tIIBf#Itl�ilfGNlftIS�CfR1i1(�OICit9�U6,AAi1(At+1FIBJECT <br />($100 Q�1 M}'�l�►biAG�R,�Rt6®I�tt�ilCrlmISM191p�y1��94tttD,A�417�1GES AS <br />PRO q ��'► hp�♦� 71Q61 ,�B�I ATIC?N, INTLREST,'ATTORNey-9 FEES, AND DAMAGES AS <br />PROV113ED FOR IN SECTION 3706 OF THE LA13OR CODE. <br />(C-57 licensed utg�orizedd re reseiVveg) <br />h <br />1, (C-67 licensst�authorlxad re�rosent�fi"A��y <br />autho ize <br />authorize <br />to sigi i this San Joaquin County Well Permit Ap I'catt(on on m�r bepia�f. J n��atRltpBtxIi�Qr <br />to sign thit. San Joaquin County Well Perml App iice tlon a my g elf y u e <br />one (1�110.JLML—... <br />year and is limited to th@ w rk plaQ P > � ?n thR &2r4AjpgA0jp,q�{34i� h <br />0116 (1) year and Is Iimitad to �he Work C a ad o <br />5-17-2 <br />