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San Joaquin County Environmental Health Department <br />JOB ADDRESS: 916 Frewert Road in Lathrop, California PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />herebY affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: PeneCore Drilling <br />License #: 906899 <br />Signature: <br />Expiration Date: 11-30-23 <br />Title: CEO <br />Print Name: Tuan Nguven Date:11-22-21 <br />WORKERS' COMPENSATION DECLARATION <br />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 <br />provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />0 Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are. <br />Carrier: State Fund Insurance <br />Policy #: 928116321 <br />certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />xp <br />aDate: 8-1-22 <br />ny manner so as to become subject to the workers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Print Name: Tuan Nguyen <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />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 THAN C-57 SIGNING PERMIT APPLICATION <br />ITuan Nguyen , hereby authorize Nicole Gotberg <br />Name of C-57 Licensed Authorized Representative Print Name of Authorized Agent <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br />en <br />