Laserfiche WebLink
r,li UO/ _Uvo ILZ. cl Z).7rJOrl-"OuDL WVU LA.'LUKAI lUN HAIiE 05/05 <br />12/27/2007 13:59 5306628052 <br />DEC -2? -2807 SI'06 crMBRIn <br />t>» <br />to <br />an <br />s, <br />rF'` <br />WDC EXPLORATION <br />PAGE 83/04 <br />V27 935 64;4g P.03104 <br />uvuuw rnvirammehf3j H99ith Gepattrtaenl Unit IV Well pour k A <br />JOB ADDRESS: -/250 _ PAlicat[oh ., <br />au`v�ilemen't <br />1 �o�d h+r��sl DSS U �v <br />LICENSED CONTRACTORS DECLARATIDN t,Cp <br />I hereby *'thine was i run Itc tsio Codnder an aravfesana *'Chapter S (commencing with Simon 7000j.;rf Division <br />3 ohne 8usine5s and Prottsslona Code er►d myoma <br />is in fall form and effect. <br />Licanse+R: � 3 /� <br />E*Mion Late: <br />Data: li a Contractor, <br />Sionatair&- .4 <br />Tale: 3' <br />Printed namR: <br />WORKERS, COAAP'ENSA110H DECLARATION <br />I hQreDy affirm under prMity of PW1t1rY one of the fb"OM g 0e00raWn4: (CHECK ONF) <br />I have ana wu1 maintain n certtAcetc of consent to seff:ineure fbr werfcem- carr►p®n58tlon, as aro�Aa�M for <br />0ll fiction 3700 of tRn Laker Code; for the perfOsm tce of the w olk for which this sallparttlt iC i xvvl, <br />.,.�! have and w;tl m►slmain wvricerg' rornpenvyon;rraurgn� as <br />tot the pelfemwWe of Owe Wolk for which thts pertrtit fsr i9eued. by Section 3Tp0 of ttre, [.akar Gods, <br />carrier and policy ftUfhb" are: AenSa6ort i�auranr 7 <br />CniTier' • 6 -;?w - r -*i r v v% IMP—sirwict Porky NUNumber904-75W — <br />I Certiry lhvt in tt,e Perfo+manr� of file work for which this + •— <br />aM rnar►nerao * a to became sut�t m tI►® workers' rom tis iaeuad, t shad not employ arty pmpan in <br />fasno� aeconte subject to the wotMM- oomPensetton provt dof (*'urs yr CaI"T a, and S.Cme thae if I <br />hwith °m" � tt X prflvletons. rstwf <br />2)cpira6on Daft: g-igmturo: <br />Prinked Name: <br />►ARNI"124 FAILURE TO SEcuRs WORR&WORVCIEM%.�rllt;=�T� <br />P rN EMPLOYER TO CRWAAL PENALriE 'dOE 0 UN VWUL. ANO SH U1 SC'N'J@CT <br />INADDMfA TO TW COST OFST, ATTOMNerg FM, AND nAMAGE7 AS <br />ROVOW Ron IN SEL'TIM Sy" log <br />AUTHORIZATION F gDffe THAN C -S7 SIGNING PERMIT APPLICATION <br />ipnature efG�i71�c4nttd eeghtx4aed nrpreteert�,uu.�), <br />feby suerorltme Wild name f <br />elfin this San Joaquin County Well Psrmlt AppNeetlon on my bohatf. I madeMteAd IN" sup+orfsadon 18 Walla[ ror <br />a (I I yearand Is NrWted to the work t:tan dated on the trent page of this aPMk1en: <br />�AM,� <br />IM 29.02.00.1 <br />C=)w <br />