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o $09/09/2003 09:44 19166385611 CASCADE DRILLING INC PAGE 02 <br />'"9/09/2693 09:56 2e94671116 AGE STXKTON F;uE 03/03 <br />San Joaquin County Envi <br />Permit Application Supplement <br />J013!AD:DREZ59an County Environmental Health Department Unn J6ff rr% Iration SuppMrrw it <br />i JOB A )DRESS: /IF -Iac�!itCA PERMIT Sly_. <br />- <br />LICENSED CONTRACTORS DECLARATION D) <br />LICENSED CONTRACTORS DECLARATION (L90— <br />J here0y y affirm that'I am licensed under the provisions of Chaptei (corn encin�,�ri Qct�'n� 7 0 f <br />3 of th�ei �@e�'�fi�' P ifi�brc}tri�rr ac�on 70000 !i <br />3 of tie 0usinesa and Professions Code and to n ee an <br />G• � <br />Date <br />Sig <br />ion <br />Print c4. na'ne' ►.. U )1 ao an v <br />woW OMPENSATION DECLARATION <br />WORKERS' COMPENSATION DECLARATION <br />I heroby afAnr under penalty of perjury one of the Wowing dacterAona: (CHECK ONE) <br />I here affirm under penalty of perjury one of the following declar tions: (CHECK ONE <br />Y I neve and ill mointant a cavdfiomta of consent to seff-irmure� wwkdrs =rpan*0Ion, �e provided fol <br />1 have of thew�o,�c who thin ermitt.i9 iasurd. <br />YA"MK TSM"& �r'MtR IP-' sure foorro g?kg comppensation, as provided f r <br />b JKey%,47,p� qQMVy�e �f t of fyv^�aR� l bd a, <br />for the pwformance of the worts for which ?his parmH is issued. My workers' comperuntlon insurance <br />I gave tJdfi6l8Wt44lf %W*,@.ompensaticn insurance, as required by Section 3700 of the Labor Co e, <br />fo the perForm o wor Chich i permit is issued. My r r ' s �syranee <br />c4rrierpFflic�1 t�� PolicyNurnbrr. <br />i .I certify that in the performance of the wort( for lhis rni is issued. I Mall not empioy any person hi <br />Cairrier.any rer 50 as to beccWme "Oet I��:i <br />should become subled to the workers' compensation mviplaps of Section 9700 of the Labor Code, I sha'I <br />I ertifyf&*Mhtb*r"F(9&p4W0Vkobwrk for which this qpyis issued, I shall not employ any perso in <br />a y mann so to,�eqome subject to the wo sa sof California, and agree that.ifstcProIIth Nnrl1lItHt!>t►1 I s all <br />fo hwith comply with those rovisiop <br />P Y P <br />Date: ice, <br />AN EIMPLOYP-R To CVjMINAL PENALM AND CML 19WS UP TO ONE HUNDRED TMU$A iW DOLLAAS <br />(31 Od000.). IN ADDITION �I rW&4Q�' I@.COYPEN?ATWN, WMRE3T, ATTOMEY'8 FEE.1, AND DAMAUS AS <br />paoVhbi i FOR IN 3SCTION 7709 Oft THE . <br />WARNING: FAI �iICIV[TDIICIARSUBJ CT <br />AN EIVVJPLOYE <br />PROVlp($100,400) ON'T COT F P STJRN�EeYd'S FETES. dAN Dn�A ES S <br />to s;pn thla Son J—"in Geunty WPI MrrMl i *n an my behalf. 1 un&rstand this #vtlrorisaWon is vabd to <br />I, —v (1) yaw snd 1. M -nam 2a OWXAPd ft .vied..n the -a' �i�pso;--j>j—zlk-gnsed authorized representatwe), <br />herebll�,pript 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✓apphi;ation. <br />8-29-02 / MI <br />