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04/10/2008 16:42"i <br />2094658773 <br />San Joaquin County <br />JOB ADDRESS: <br />IWC <br />i:nvi;FeMental <br />moo <br />LICENSED <br />PRECISION SAMPLING AGE 01 <br />Ith Department Unit IV Well Permit Application Supplement <br />eA PERMIT SR#: <br />//O N. <br />+FORS DECLARATION (LCD) <br />I hereby 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 effect. <br />License #: 636387 rr �� Expiration Date: 1 31/2010 <br />Date: L4— 9 i , Contractor. Precision Sampling, Inc. <br />Signature: Title: _.Location Manager <br />Printed name: Brenda Cracufnrr7 <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 consent to 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 have 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 policy numbers are, <br />CarrierLibet<V Mutual TnsTi7-nt Policy Number: WC11371072339027 <br />1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: 6/ 3 0/ 2 0 0 8 Signature: <br />Printed Name: Brenda Crawford <br />WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL. PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THI` LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />iereby authorize (print name <br />ignature of"7/�icensed oriz^ed represent},]tive), <br />o sigh this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />me (1) year and is limited to the work plan dated on the front page of this application. <br />i MI <br />EHD 29.01.401 <br />6122M4 <br />