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10/1E,QOK 13.:58 19166385611 CASCADE DRILLING INC <br />WED 12:54 FAX 1 918 861 0430 SECOR-WRADIEvTO <br />AGE 09 <br />X002 <br />San Joaquin County Environmental H eatft, Services, Unit IV Well Psrmlt Application Supplenwnt <br />J08 ADDRESS:PERMIT SRX: <br />or <br />LICENSED CONTRACTORS DECLARATION LCD <br />I hereby affirm that I am licensed undsr the provisions of Chapter 9 (commencing with Section '000) of Dlvieion <br />3 of the 9usine3$ and Professions Code and my license is In full force and effect <br />License is. -.C -,S r- ( 7/7S70 Expiredon Osie: <br />Date: �� ' D '0 Contractor: C 0 `S C <br />-- trJD� Fc <br />Signature: Title: CZA M9 <br />Printed name: Vera- C 0 D M C'. <br />WORKERS' COMPENSATION DECLAAATIl�N <br />I hereby affirm under penalty of perjury one of the following declarations: (CHELK ALL THAT APPLY) <br />I <br />I have and will maintain a certlficato of consent to sell -insure for workers' compensation, as provided for by <br />Seotten 9700 of the LAbor Coda, for the performance of the work for which this permit is Issued. <br />I <br />X, I have and will maintain workers' oompen3ation iinsuranoe, as required by Seatlon 3700 of the Labor Code, <br />for the performance of the work for which this permit Is Issued. My workers' compensation insurance <br />carrier end policy numbers are: <br />csrrl/r. jd_a$ ka fit 7"I d ► I tTI Policy Number. 0 0 - LW S d 53� <br />—I certify that In the performance of the work for which this permit is issued I shall not employ any parson in <br />any manner ao a9 to bevvrre aub;eot to the workers' oompensation laws of t�allfornle, and agree that if I <br />shood become subject to the workers' compensatlon provisions of Section 3700 of the Labor Code, I shall <br />fonhwtth comply with those provisions. <br />it <br />Date. % r�� d O — 61enaturs: <br />Printed Name, ��{ C( Y**'" <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSAT10N COYLRAGE is UN%AWFUt, AND MALL SUBJECT <br />AN EMPLOYER TO CRIUIWAL PENALTIES AND CIVIL PINES UP TO ONE HUNDR96 THOUSAND DOLLARS <br />(6100,000.), IN A0pMON TD Tma COa'i or COMPeNDATION, INMr-ST, ATTOANkY'S; AMS, AND DAMAGES AS <br />PROVIDED FOR IN SSGCTION 3706 OF THE LABOR CODE. <br />E <br />Ve rck l,. c ,y, C 0-' _(signature ofGBT Iloanaad authorized i "N efferwNej, <br />hereby a uthvrfte (print <br />to 41grn this San Joaquin County Well Permit Appllostion on my behalf. I understarid this authorization Is valid for <br />one (1) year and is irn ted to the work plan dated on the front paOs of this appltoatien. <br />