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w <br />Oct 23 01 03:59p Spectrum Exp. <br />209-465-8773 p.2 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Applicatlon Supplement <br />JOB ADDRESS: S cJfK� PERMIT SR#: <br />--f Y"A <br />LICENSED CONTRACTORS DECLARATION (LCD -) <br />I hereby afirnm 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: C570 512268 <br />Expiration Date: <br />04/30/2003 <br />Date; Q ;(2 6 ! 4 Contractor: Spectrum Exploration, Inc. <br />Signature: <br />Printed name: Bre <br />Title: Operations Manager <br />ford <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm k -r- .-L , !t'f >-. ury one of the frlowtrry declarations: (CHECK ALL. TH4.T ,APPLY) <br />I tyre 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 perfarniartce of the work for which this permit is issued. <br />S3_ I have and will maintain workers' compensation insurance, as required by Sectiori 3700 of the Labor Cade, <br />for the perforrnance 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 />T I certify that in the perforrnance of the work for which this permit is issued, I shall not employ any person in <br />any mariner so as to become subject to the workers' compensation lacus 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: %(� j Signature: <br />Printed Name: Brenda C wf ord <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 ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />IBrenda Crawford of Spectrum Explor .(signature ofC-37 licensed authorized representative), <br />/i . 0 11 �I_.n _ A "2n D n It <br />hereby authorize (print name) <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 />5-17-20001 AAI <br />