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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 2057 SOUTH EL DORADO STREET, STOCKTON PERMIT SR#:{gyp <br />i g2,4's <br />LICENSED CONTRACTORS 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 #: C57-680227 <br />Date: 12-18-2006 <br />Signature: <br />Expiration Date: <br />11-30-2007 <br />Contractor: ADVANCED GEOENVIRONMENTAL, INC <br />Printed name: ROBERT E. MARTY <br />Title: VICE PRESIDENT <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />xx 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 />XX <br />_ I 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 />STATE COMPENSATION INSURANCE <br />Carrier: FUND Policy Number: 1317474-200S <br />I 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 ensa ' e workers' compn pro .sionso Section 3700 of the Labor Code, I shall <br />forthwith comply <br />with those provisions. <br />Expiration Date: 10-1-2007 Signature: U <br />Printed Name: ROBERT E. MARTY <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 THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-021 MI <br />EHD 29-02-001 <br />6/22/04 <br />