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San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS : 1301 East Lockeford Street PERMIT WP # : LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect . Contractor Name : Environmental Control Associates Inc . ( ECA) License # : 695970 Expiration Date : 09/2022 Signature : Title : Owner Print Name : Tim Tyler ( Owner) Date : 6 . 15 . 22 WORKERS ' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations : ( check one ) I have and will maintain a certificate of consent to self- insure for workers ' compensation , as 17 provided for by Section 3700 of the Labor Code , for the performance of the work for which this permit is issued . I have and will maintain workers ' compensation insurance , as required by Section 3700 of the IN Labor Code , for the performance of the work for which this permit is issued . My workers ' compensation insurance carrier and policy numbers are : Carrier : *ON FILE WITH COUNTY Policy # : Exp . Date : I certify that in the performance of the work for which this permit is issued , I shall not employ any person in any manner so as to become subject to the workers ' compensation law of California , and agree that if I should become subject to workers ' compensation provisions of Section 3700 of the Labor Code , I shall forthwith comply with those provisions . Signature : 01; Print Name : Tim Tyler ( Owner of ECA) WARNING : FAILURE TO SECURE WORKERS ' COMPENSATION COVERAGE IS UNLAWFUL , AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $ 100 , 000 , IN ADDITION TO THE COST OF COMPENSATION , INTEREST , ATTORNEY' S FEES , AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C -57 SIGNING PERMIT APPLICATION I , Tim Tyler ( Owner of ECA) , hereby authorize Lauren Flinch ( of Partner) Name of C-57 Licensed Authorized Representative Print Name of Authorized Agent to sign this San Joaquin County W7ii fio ' ng Permit plication on my behalf. I understand this authorization is valid for one year and e k an dated on the front page of this application . Sig tura C-57 Licen d t orized Representative EHD 29-01 8A1 2017 Site Mitigation Well/Boring Permit Application