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Aug 05,,02 11:09a Spectrum Exp. 209-465-8773 p.2 <br />yF _ <br />San Joaquin County Einvironmentzil He <br />$ewijdes, Unit iv weu Fermli h}iNcn,nti,�.,. _-•rr - <br />T �: <br />JOB ADDRESS: <br />LICENSEDLICENSED CONQT&&g �"" 4l'DN (4=) <br />In reby affirm that I am licensed under the provisioos, of C ivision <br />3 �+ee `t !' fK fl ® i b dh�1}PMjjt s ° p ��(8 fi �►'t'ittl� �rY�@�Q� vision <br />3 Business and Professions Code and my tcen� f8f14®r6@�ffetE�c.t' <br />Lic nse Expi %iWt) 04/30/2003 <br />License #. C 5 7 <br />Da Co tract r: Ex loration Inc. <br />Date: <br />con �rac-tar.L - ,12 L it, <br />Sig ature: Titlaitle: o erations Mana er <br />Signature: <br />Pri ted name: ford <br />Printed name: gA� <br />WOf M8jjV"T@ R%� ,k rpN <br />I he by affirm der I r tttl Lio ((CCHECK ALL THAT APPLY) <br />i Y rM �e� tsf b i NECK ALL THAT APPLY) <br />_ have n ure forworkers' compensation, as provided for <br />��. It �l i I i�Rl litQrt � r w j ' yJl Tpg(�{ pmijtaS 06*ed for by <br />7 1 ,(i�mdl ��lei r�e wor�C for which this permit is issued. <br />I have surance, as r uired by Section 3700 of the Labor Ca <br />DP61 � ti8�liili� i R��iQ�a�ic�ti ��p �eMPWC �1�od3rxp�T►�aVtWLWf 'tie, <br />fbV"rW6ftMMe eft 0*kEK lM�i t ssue 'J workers' compensation insurance <br />Ca <br />s <br />i <br />fl <br />j Date: <br />i <br />i <br />WARN <br />AN EM <br />($100,{ <br />PROVI <br />s <br />�rr er,%M&u0M ppitay muramrs a, e. <br />rier,C,rri n American Motorist Policy Number: 3BG03575800 <br />Number: <br />f� n <br />work <br />rkfor which this permit is issued, shall <br />�{ +h��,_,��.:...:,...�:.r.,,i os. r-stlifomia._and agree that if i <br />y maanVn c; @ �t gr `�{t <br />ould il�onid�9@ly�@t�bgr °Frfrensatior <br />thwitl6ocltlw�S��F�3(o`���8�c�ns. <br />i9alliep, preu uian" ePloallrorma, zlna agree that if I <br />provisionshl Section 3700 of the Labor Code, I shall <br />Date:/5 / �� Signature: 7 <br />��4��aiure: <br />Printed Name: Brenda Uewlulu <br />Printed Name: D SHALL SUBJECT <br />T�CSECURE WORKERS' COMPS HUNDRED THOUSAND DOLLA <br />R1Mil LtD$1ANR i�� Edi l RUVI' WUSHIMP 9610 S <br />1 8�-'ii1ii54b8y1fi81E� ?ZED THOUSAND DOLLARS <br />I�1WT*Wr0W0f10'�dt1,ARPRA, REST, ATTORNEY'S FEES, AND DAMAGES AS <br />CTION 3706 OF THE LABOR CODE. <br />ll'Brenda Crawford of Spectrum Explor -(signatures ofC-57 lcensed thorized represents ve), <br />�' <br />lhori <br />hereby authorize (Print name)Y <br />p apIn this San Joaqulrl County behalf. I understand this authorization Is valid <br />sign '3IX*t rn County Well Permit qq�� ttic <br />,one 011 year and Is limited to the wort laRai68rbF %6'ycif•Phg-dhtbkt?IM fr3tWflhorization is valid for <br />e (1) 8r'afrd is limited to the work plan dated on the front page of this application <br />6-17-20001 MI <br />200 <br />.'7= <br />