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07/07/2004 10:21 2094671118 <br />Jul 07 04 09:54a <br />07/07/2004 06:44 2094671118 <br />AGE STOCK, <br />AGE STU-<Ta <br />San Joaquin County Environmental Health Departmelnt Unit IV Well Permit Application Supplement <br />JOB ADDRESS: FERMI -SR#: <br />cCounty £ mi <br />n Joagwn nvironmentui .sit1� I�et3 <br />°'E C��i� DECLARATION (LCD) <br />I hereby affirm that I am IicensedNkkQ&9*TMWTfQ%ter 9* (cdAtrencing with Section 7000) of Division <br />3 of the BWsiness and Professions Code and my license is in full force and effect. ,tion 7?t, <br />II here y_„ ...ha. orovisiom, ofC jA sr9 'Ia,. <br />License 4:i id pro's- - Expi n#h bate: <br />Date: I xnst l4 - r.�.,..^—E;Pir.' <br />Signatu <br />Printed n <br />Title- <br />WOR IPOMPFaNSATIQ"EALARATICW <br />I hereby a�irm LTft(#per*"'(5PP3rjury one -of the following11d0$fMnsP` (CAi * 6N�) + <br />. I t a. "ill main � w1 . e -Rffi leof G ae(f4nsu X N' 2r%'Cc, "(t 0n, as provided tni <br />I have and W-1 self�tr�ps,)gl�lrke[s'.iah�enpetiai't2ee4wdvided for <br />by Section 3700 of the Labor Code, for tt'e performance of the work for which this ermit is issued. <br />..iio maintaiin rk <br />woed compensai.. !WCC, a 'oqv �•" "` UADer Cc <br />_ I havd and will m;r, tar w(Dfl4tt�pCt fipf@l)w9 t Ab OsurancLs,ib%ufbgAIT by Section 3M806f'INor CodE, <br />for the performa'Ice &T 'he worrf89hich chisterm;t is issued. My workers'mpensationlsurance <br />�-arrieq and policy num f ire: 5' -jet Nuri' e, > = vt r <br />r;aY--.e1 : (ce :n the Deftrlr1*Aca or is foFAMi0yvtiunnisetis <br />ani' '.`toll ampi�. <br />y -o as to become suDjC�. 11P rk.. ' eOMr'i• 'nor' an <br />I certii that IR'the perfottflP►2%4ft&Ql0k,-Jcr wPtfc"itis pnnit is sued, I shdP RR'60' (ip''oy any persA ir� <br />any m nner'�tas to becoMPT(SBRPYRI'e workers' compensation laws of California, and agree that if I <br />shoulc Oecome,subject to the workers;i$nsation provisions of Section 3700 of the Labor Code, I shall <br />forth th compiy with those provisions. <br />Print. Na,nc- <br />Expiratio Date: Signature: <br />W, .,,. wot <br />AN EMPLO', '!MINA. 'LTIIES TINES V ."PC E N! _A, rH0 10 0 �4 <br />r 100,004j, PriTided NarrmOF,- _NSATtOF TV 'r re>4 .if �.SA5 <br />-MiCilm O0 SECURE ��YN,,QQ57��t� 'H COoD,E�� FQ�- <br />AN EMPLOYER T WARNING: FAILUR M NAL PENAL'T I OCIaLtI: FIA TE3�P O ONEANU I� UL,;C,% L'ARSL,SUE?JEgT <br />($100,000.), IN A I N TOP, E� �CO C MPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED TIOW5: 6 OF R CODE. RYI <br />hereb Outhoi )Tint name \\r � �% <br />r <br />AUTHORIZATION FOR OTHEh THAN C IGNfNC F'&Wlft AP#LICA'-- <br />a sigr1 tl+:s Se • -- soPn courlt'� arma o sehatf. I e►Is All is 'd ft <br />I, ft) year Aria Is NMI" $an 4 t+ (%j%"tjrde ofC-57 Ucensed authorized representative), <br />hereby autho, & (print-mame) <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />.10 29-Qm! <br />one (1) yearDMW 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 />9/30/2002 <br />