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JAMRAO PAGE 01 <br />SPECTRUM EXPLORATION <br />1_/19/2002 14:31 20945587'13 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Su t <br />�p, cation Supplement <br />JOB AD 11 I HQaltb services, Unit IV W La�i�T p M <br />San Joaquin County�ETo^Tee <br />' g7� �;�PERMIT SR#8 ADDRESS OORS DECLARATION (LCD) <br />R nECLAFL4TION (L,�) <br />I hereby affim�t�ati �Q1�T�dh�f Chapter 9 (commencing with Section 7000) of Divi ion <br />3 of`the Business and Professions Code and my license is in full force anc UWkh Section 7000) of Division <br />m licensed under the provisions of Chapter 9 (coa d effectt. <br />1 4�ro* that 1 a s4E>*ir�fldh ff ge. <br />3& the Business and rOTCSSIuj is eode aPda4"y____ <br />g130f03�� <br />Date: 2268 Contractor: Expiration Date <br />Li nse #: _ 51 <br />Signatur rum Explorat'ontJ011 <br />Conti <br />D ate, I <br />anted name: Title: –Operations Manager_-- <br />. <br />PS gnature'. <br />rinted name: _Brenda Crawf <br />KERS' CO <br />I hereby affirm under penaWde M POrCGA6Vg-N§A*T�� c a�rations: DECLARATION <br />) <br />s: CION CHECK ALL THAT APPLY <br />(CHECK ALL THAT APPLY) <br />_ I have and will main i 1 �j��bC �oNQt ► )f i �o�workers' compensation, as provid r for f�y <br />f heret$6016iYi rcPTPROa�o C� for the performance of the � ,la l taatit t ipS E�?d 1�or by <br />I aintailn a certificate of consent t0 self -insure <br />work forvqhich this permit is issued. <br />khave ai YWI. 3h1Pp MWA'MJA9, as required by Section 3700 of the Labpr d�, <br />IS16PKeYERog ance of the work for which this permit is is�sy�ic�,W�- gSc,COM tsafi�ins�urance <br />carrier a d. I' HI W*&C. compensation insuranc workers' compensation insurance I <br />x I have an�'v�n��ri�aYr> <br />�Pertom-,once of the work far 4vhich this permit is issued. My <br />Policy Number: <br />carrier a <br />��nrk fn umber:, 313G03575800____---- <br />I <br />BG03575800 <br />l Icertify ton g�Rodf6 lt)ce of t_hP __oA9 i Yi fhis permiiis issued, I shall not em lo an a R inl <br />A��� <br />�ary4 rnr ner so as to become subject to the wo\rA�e,co ryn�� , tjgr ,df�NlffO i�?�� �`e li I <br />sho d t�Qd� i ��' atrho ee��frtd s r a l RIGA iofiWWNAhW �,sll�jj all <br />— I �if�, r eta <br />any mal�h Q� ` lb ��� ' rovisi s of Section 3700 0# the La or <br />Dat hould became subject to the workers' Compensation p <br />1ortt1with eerpoy wth those pr��1�51��re: I <br />Date: <br />da <br />ft�f Cra ord — tg>�¢T <br />WARNING: FAILURE TO SECUh"860**gg�pSATION COVERAGE IS UNLAW L, <br />AN EMPLOYER TO CRIMINAL PENALTIES AND T�Q�RAd51�1t;fl�'�Y <br />jbIQKCi TION, INTERA ft�4 EST, AI TORN Y' <br />(5100,000.), IN ADDITION TO THE COST <br />IPROVIDED FOR IN SECTION 3706 OF THE LABOR COnE. Y (C-57 licensed autho ' �r WJxv gkereby <br />aluthcg� Crawford of Spectrum Exploration, Inc._(Si9nature ofC-57 licensed au <br />��®6yt�t�rlald3djlliln pkation on my b behalf unis <br />er*�����lbion Is Valtl@rr <br />yV II rmit Application on my <br />(;I�ryeWis idQltflk��C84ii vor�C plan dated on the front page of IMPSPO&'13n. <br />N. <br />d n the front page <br />�oI�land is limited to the work Plan dated oo <br />5-17-20001 MI <br />