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V iJ/ L�JeI IGLVi i � . f�Vi'1 I'IV lf�/ rr�l/ VYVVVVf�: VVG GI�J.' JG.' 7..�JO 7.�FF �v�fjNrFr .ti►Tj►i,F��` Fr7 F7`77771:0PFY1V�f yRFliar irprl l;r'R7.I}�,�a r'FJ+)+MY4RI VIF VY�+pIv , p 8011TH. CryEROKEE LOD 1, Ch 45240 1 - i LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapte, 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. L.icerse#: 408595 0-57 _ Expiratior Gate: 07/01 Date: 6/8/00 Contractor. EARTHTEC, LTD. Signature: n rti Gi nt1g; PRINCIPAL CONSULTANT Printed name: MR. ED HENDR I CK WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following decJarations: (CHECK ALL THAT APPLY) have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. X 1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier. _STATE COMP INSURANCE FUND Policy Number. 1353921 _ I certify that in the performance of the work for which this permit is issued, I sha!I rot employ any person in any manner so as to became subject to the workers' compensation laws of California, and agree that if t should be :orae subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date. 06/08/00 Signature Z— Printed Name: MR. ED HENDR I CK WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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, I, (CS7 ftcansed authorized representative), hereby i authorize to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one M on -.3nY.. _ is limited to the work pian dated on the from page of this oblcalovr