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OS/1S/2007 12:55 9253130302 GREGG DRILLING PAGE 02 <br />08'15/2a07 12:e7 5306756005 STRATUS NO CALIF PAGE 02/02 <br />2/ <br />San Joaquin Connty I;mr7rvnrrlernal MealM GeparIMnt Unit IV well Permit Appllcatlen Supplement <br />JOB ADDRESS: -"N' .1 oe v A PERMIT SRX:_ 1 ?2— <br />LICENSED <br />Z <br />LICENSED CONTRACTORS DECLARATIONLf CDj <br />1 hereby affirm Dot 1 urn Iicc mn under the provisions Of Chapter 9 (romnweneins with Section T000) of Division <br />3 of tho Sucintss and Profe/sslonc ode and my ll=se is in full force and effect. Q <br />Llcense; (t/ Expiration bate: <br />Date <br />ftnaturs: <br />Printed <br />W0RKM5' COMPENfiA110N DECLARATION <br />I hereby affirm under penalty of perjurer one of the foiimMng declarftons: (ONEoCK ONE) <br />I hai a and wdl maintain a oeriPBt:ate of consent to 3ulf-blzure fir woftrs' eempensatim. as faW&d for <br />by Section 3704 of the Labor code, far the performance of the worts for whW thfs fel mA is issued. <br />1 have and will ora' htain workers` eomponsation int =rme, as required by S eativn 3700 of the Labor Code, <br />for the perlbrmnce of the work for which this perml is issued. My workers' aompest�ation insurance <br />aanser and polrey numbers art~ <br />c-mvior r l Policy Number, 10-7 524o <br />nattily than in the perforrrartoe of the work for which this perm9 Is Issued, I shall not employ any person h <br />any manner so as to become s0jest to the work wn. G=pens3tion laws of Califomio, ar+d agree tW if I <br />shoouM become mublect to the werltoK' eempol tbri pr 4sions of Sectio D Of the L2bCr Cade, r shall <br />forthwith eorrrpiy with thpse prowians. <br />EKFiration Oats: a Signature: <br />Prlatw Name: <br />wARPMG: FAILURE TO SEWRE kMRNEPW COMPENSA'"ON caVERACE IS UNLAWFUL, AND SHALLSURJC-[ <br />AN EfItPLCnrER TO ORINtll1AL PENALTES AND CMM. FIM LIP TO ONE H1MDRM n OLISAND tydt.t,AM <br />4100004 IN A»OMGN TO THE CCU OF COIIIPENSAit N, W ERMT, ATTORNEYS FEES, AHD DAMAGES AS <br />PA&ADE0 FORM SE MIOH 3705 OF THE L AWRCOW— <br />A IrR THAN C•57 $iGNmr, PERMIT APPLICATION <br />�, (sMgtmt�se OM -67 k0endaad.yaw9mr1wd rvp,=v", <br />mmby Oudwrite ifartrtt rrwnpL, iYrTI+HSAri) . ��IU li1Lt19rlterSlP. �ta�_ <br />o sign this. Sun .foiiquln county iM o l Pemit Appllrattvn on my bonW. I undersrtantl oris auMo traftn rg mild for <br />►he (i)yaarand In Ilmlead to the wvrk plan daaad on 1ho ftntpugs of this apph=tIon. <br />!FR <br />EHD 19-0-m <br />6MAK <br />P�A /PA AT -it'.`) nN qn i "N i q Cnngq 1 gnpc qp, :) n ? nn7 rc T +r n <br />