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4 Jul,Zl. ii)0 I:JdFM Advanced GeoEnvirenmenlal <br />(o; I(i�I'/re �j3*' <br />Na.14H P. 2/3 <br />Sarr��BaHiit&R41q�0}ntmt>wfal Hea�ttiirtFaatl�kitiit/lM(f�l�jalTuff <br />(l <br />EHD 29-02-001 <br />6/22/04 <br />r�pt"O""MiF <br />it <br />dcitya4Lfj Civ <br />PGdy11�i7�R#iD� 7%2UJ <br />U vo <br />I hereb affirm Bial I am licensedu,n,�rrr� provi i of <br />�{iMS�'h����rt�Ficc�i9jP�iv <br />Sion <br />3 <br />f the Buslnerot s iand y icenseis in u %License <br />--> j <br />Li <br />it: pate <br />#: �pi al on Dat <br />tense _ _ . <br />Date: D Gantmcto! <br />D <br />te: ntra <br />Signature: Title= <br />Signature: <br />4 i Title: <br />Printed name: <br />Pi <br />inted name: <br />WORKEI PENSATION DECLARATION <br />WORKERS' COMPENSATION DECLARATION <br />1 hereby aMim under penally of perjury one of the following deciarmtions: (CHECK ONE) <br />I I <br />ereb f of e %f the ` !12 decl rations: (CHECK ONE:) <br />_i� as consent tO"se��-nitsure wortcens rnrrepensation, as provided for <br />3700 in the t ahoy Code for thezertorTn�AeFR Q�il r K <br />h7ilhnmai£n;ta�inCLa�{c�ertlrfi�c.�ajt.���of co,,.:ento s�e[�.- � r P� �i`a���{��L +y�-�.,,�P4it�-provided <br />MNW �F3NI�RW�IXfCCfS `E�j��l.c r 'RIS[1f3R���a7L'471U1 JIWUIr i It �S..1�.:.$L�_J_. <br />LwV(AWG <br />9the <br />or <br />formance Of the work for which this permit is issued_ My wofk i <br />I h=nieridndi i r�;s' compensation insurance, as require.Ay c iosn fIO rFtabor Code, <br />for the pe once f the work for which this permit is issued. My crkers' corppensation insurance <br />ca tai Policy Number. <br />CAig ftify that in the Oil work for wtiachftilipprfiiiRrl bmued. I $haft MI erpp►Qy <br />any manner so as to thie workers' compensation laws of Cardo nia, and agree (trot 16 <br />I ;Wgm74te �r i E�i��1�14��f�tVal�b�eibgl�atn��rtrs <br />n in <br />nn9T , c ,-to the w s' gompensatio law f California, and agree that <br />I <br />Ei0wiW60i'comp sail p isl of e i n 3700 of the Labor Code, I <br />hall <br />forthwit co . <br />Print <br />�r CQ— <br />F <br />piration Date: Ig <br />WARNING: FAILURE TO sEcuRE v1MERS, COMPENSATION COVERAGE IS UNLAWFUL„ AND SHALL SUWECT <br />AN EMPLOYER TO CRIMINAL F9 alViriB 1C <br />4100.000.j, IN ADDITION TO THE COSI OF C06APENSATION, LNTERES f, ATTORNEY'S FEES. AND DAMAGES As <br />AR1P��Lt1@1SATiON COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />A <br />(1100,00 <br />q EMPLOY B PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />1 I F 1 1MCiCT,816MM (eR W-APPLCAVIAJjAMAGE <br />AS <br />P <br />.P <br />ROVID O N EC ION 701AF 7 E E. <br />AB R COD <br />1. signature oW-67 licensed auori ed <br />fieirby IHr¢"Oe plrt t T1 N OT T -57S ING E I XPP�A : <br />I, <br />t e t sist s <br />Ionsvid <br />tivel,ndn79N,,1t <br />h <br />t <br />uin C n Well Permit A lication on m behalf. I understand this authorization is valill <br />for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />EHD 29-02-001 <br />6/22/04 <br />