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a,; r_6z� Xb� <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: o Adams st, Tracy, CA, 95376 PERMIT SR#: <br />Se?1. <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 #: 680227 <br />Date: 9/14/07 <br />Signature: <br />Printed name: Robert Marty <br />Expiration Date: 11-30-2007 <br />r'7ntractor: Advanced GeoEnvironmental, Inc. <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 />X 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 />Carrier: state Compensation Insurance Fund Policy Number: 1317474-2005 <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 Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: 10-01-07 <br />Signature: <br />Printed Name: Robert Marty <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 TH <br />hereby authorize (print name <br />SIGNING PERMIT APPLICATION <br />ignature ofC-57 licensed authorized representative), <br />to sign this San Joaquin CourXWell Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limite0o the work plan dated on the front page of this application. <br />8-29-021 MI <br />EHD 29-02-001 <br />Fmm4 <br />