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SR0053517
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2900 - Site Mitigation Program
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SR0053517
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Entry Properties
Last modified
9/21/2022 4:00:29 PM
Creation date
9/21/2022 2:49:42 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
BILLING/PERMITS
RECORD_ID
SR0053517
PE
3503
FACILITY_NAME
BLVD AUTO 3SVP off CoROW
STREET_NUMBER
2128
STREET_NAME
ELMWOOD
STREET_TYPE
AVE
City
STOCKTON
Zip
95204
ENTERED_DATE
3/4/2008 12:00:00 AM
SITE_LOCATION
2128 ELMWOOD AVE
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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Tags
EHD - Public
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J A <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: County Right -of -Way, Elmwood Ave. PERMIT SR#: 0051 <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 #: C57-680227 <br />Expiration Date: <br />30 NOVEMBER 2009 <br />Date: 25 February 2008 Contracto AD CED GEOENVIRONMENTAL, INC <br />Signature: <br />Printed name: ROBERT E. MARTY <br />Title: VICE PRESIDENT <br />WORKERS' COMPENSATION DECLARATION <br />I 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 provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />XY. 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 />STATE COMPENSATION <br />n,,,.,,, l "4l 7474-9nn7 <br />Carrier: <br />Policy Number: <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 provisions of Section 3700 of the Lab Code, I shall <br />forthwith comply with those provisions. <br />01 OCTOBER 2008 <br />Expiration Date: Signature: <br />Printed Name: Ro ERT E. TY =�'�4�" �• <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, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />ROBERT E. MARTY <br />(signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) TIMOTHY J. CUELLAR <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 />8-29-02 / MI <br />EHD 29-02-001 <br />6/22/04 <br />
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