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a7f27,12005 13:45 7073745677 WOODWARD DRILLING CO <br />a TI IL. 27..2005 12= 19PM nPE ; ENVIROTCCI-I, INC. <br />pLt,tJ I� 2� 5A <br />PAGE 02;' <br />NO. 417 P.2 <br />San Joaquin County Environmental Health <br />Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: (D� lJ �J Eani1 L t1 t.,LbGI �+ CI� PERMIT SR#.: 0 Oil <br />LICENSED CONTRACTORS DECLARATION WED) <br />I heroby 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 effbct. <br />License #: 1071 si( Expiration Date: 3,110 -7 <br />Date:oZ%� �SContractor. Li ryl <br />` II <br />8Ignature6nZJZ1er4 — 4,- i <br />Printed name:(Din r l <br />I <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 consentto 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 />✓1 havo 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 polliity. numbers �/�(� <br />Carrier: ,) � Policy Number' MAO— 9%3%— aq� <br />I certify that In the performance of the work for which thio permit Is issued, I shalt hot employ any person in <br />any manner so as to become subject to the workers' compensation lows of California, and agree that if I <br />should become subject to the workers' oompensstion provisions of Section 3700 Of the Labor Code, I shall <br />forthwith comply with those <br />provislons. f <br />Expiration DatA:1Q. �.! �J Signature: - 5..� <br />Printed Name. <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWOUI., AND SHALL. SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($1oo,000.), IN ADDITION TO PVHE OF THE LABOR COMPENSATION, pITEREST, AT'TORNEY'S OEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION <br />AUTHORIZATION FOR OTvH�E THAN C-57 SIGNING PERMIT APPLICATION <br />I, , Q/ (signaturoofC- Iceni,iauthortzed representative).i <br />hereby authori;% (print name <br />to .sign this San Joaquin County Well Permit Application all my behalf. I understand thin authorization Is valid for <br />one (1) year and is limlittl to the work plan dated on the front page of this application. <br />8-29.02 / I <br />EiM 29-02-041, <br />6/22/04 <br />