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00 7073746577 WOODWARD DRILLING CO 4GE 03 JAMM[fll _ San Joaquin county rnvironmvrua•, r,eaiu , ted, yfcu-, unn — vrvn re, n++, i i UOHNOW C0N'I`RO.TKUMPO L: ii�EART 9rbiI L PWD) i I he4�� ff '('CFI�`talt� i�1i � � ��i �r��i Q�1 °� C i ir ��r��neI ing wi c ec io00 j o 6ivision 868 " 3 f'e'et and My cennsesis"in u P once and e act. _icon e # 7(00 Expiration Date: 7 3l- 0i _ Li ense#: Expiration Date: qa a - - Q Contractor')flt,J tPr Date: ctor: S gnature: Title:—.to Signature: r _ Title: t ?rintvd nam*: Printed name: ! hereby arflrm under penalryWipetjvErrSCgt''r',�7cft L'C1�Y2ttorT5L�LL THAT APPLY) I hereby)aflld'�a�4b'f R�fh��2h�ffitit®�r#rfc�k}tlh�,sl�el�yerisser$'Cldr�+s4ttt�nTq�T°Ai11 b,' 3e.hor 3700 of the Labor Code for the performance of the work for which this permit is issued. I ave and will maintain a certificate of consent to self -insure for workers' compensation, asrov dad for by �i�a�a® e1��tkt�it7rN(9b�5'f�pm�p��2�ah�v��i�o� ��4A,Rf�oce icr the performance of the work for which this pe: mit is issued. My workers' comp nsabon insurance I hIWi4i�hWVi '�il�AM'.compensation insurance, as required by Section 3700 of the Labor C de, for the g-�Sf tt ryy�r /�r which this peri ,i� r1V1y[Cy�4 cation insurance r: ca�'neamr an I cerify that in the performance of the work for this permit is issued, I shall not employ any person ,n C67-rIW1 manner so as to become subject to the work�mlooSrpl�tti�ft aws of California, and agree that if Gui4 become subject to tte workers' compensation provisions of Section 3700 of the Labor Code, Is ,K. I ceifbfyt,0 taio40ype>oaao,; gf4*14vork for w Ach is p rmit is issued, I shall not employ any person in any ma. er oast ecome subject to thew r; ' o ens laws of California, and agree that if I tilt'@fi�"�8 M2tr6rCode; I shall forthwith comply with those ro is 6,�/� rr7 I�ri n�et11�irn e: oeS ST,� DatevI �WJ COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES Up TO ONF HUNDRED THOUSAND DOLLARS (5100,000,), IN ADDITION TO yWrnV6gy4Gl%nEj9MPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAaES AS PROVIDED FOR IN SECTION 3706 OF THE LA WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN' MPL O fj,.�tFS AND CIVIL FINES UP �T(��IJ�;Qjijji!gi1�19�>y (Sita;� INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PRO au4rC?ie0�7��3 4�F►+�•4f� R CODE. to sign this San Joaquin County Well permit Application on my bahalti understand this autt,orixaticn is Valid!:., I, (C-5� licensed authorized representative), hereby cin* (1) year anti is limited to the work plan datedon • ron page o this application. authorize LLII: /Ml to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1) year and is limited to the work plan dated on the front page of this application 5-17-2000 / MI �tJ ?mrd DIVO�S3Qa� SZZ�,�6Cg-60L C[ 2Z i00Zi0?.�'"