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Jul <br />07,11/00 TIE 10:33 FAX 1 916 861 0430 <br />FROM : West Hazmat FAX NO. <br />07/10/00 MON 18:53 FAX 1 916 861 0430 <br />04/26/2000 88!23 2894683433 <br />SECOR- SACRAMENTO <br />: 1916638ES-13 <br />SECOR-5ACRAMENTO <br />rrrH FlaIR <br />Z 002 <br />11 222007 <br />014 <br />1:: <br />':SaiOn'ei3Otn: CPA riti EtvirnnmentalItealtri - icisur Lintr- 01-7-C.A .—T.—Vet Pe"rritiiilledtkiri-Sifilijarriont;' ' <br />......---:';1.---; --: <br />014Liilti00:: V, 5 , -s....,,,44.,,v, F‘40iiiit.Rfit. 0023 ___. <br />.. . . - .. 2 -ti"c;'-:13 fp•- 2-114iL <br />2A q ..0-7 D-- 0 <br />2 1,19 - o4o -cat z 3 70/ 5 Sa".6. Fr <br />LICENSED CONTRACTORS DECLARATION (LCD.) <br />I hereby athrm that i ern licensee under the provisions of Chapter 0 (commenoinr; with Section 7000) of Division <br />3 of the Business and Professions Code and my lit-Anee is in full for and gfiect. <br />License #: 5 5 41 (4/ ci 7 Exphition Date: &f - 3/- 0/ <br />Data: j I - or? Contractor: LJE 5 A- _ \-\--,) Cite p ilkArr,L,, <br />Signature Lc---•4° O. k/.. Relb,4.A.)At_ <br />Printed na <br /> <br /> -_clzitArr <br />WORKERS' COMPENSATION DECLARATION <br />I heleby affirm under penalty Of perjury one of the id:awing doolerations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to eelf-insure for worKerah compensation, as provided for by <br />Sechon 3700 of the Labor Code. for the performancs of the work for which this permit is issued <br />...,ZKave and will maintain workers' compent.ation Insurance. es required by Section 3700 of the Labor Code, <br />for the performance of the work for venial thie permit i,1181thuact, My woricomi compensation insurance <br />carder and pallcy numbers are: <br />/ P-401-1-449% <br />__,/ <br />certify that In the performance of the work for which thla permit is iued, I shall not employ any person In <br />any manner so as to become subject to the worker' comptinsetion !awl- of California, and agree that It I <br />sheUld become subject to the workers' compenuatbn provIsions of Section 3700 at the Labor Code, I shall <br />forthwith comply with those Provir•ions- <br />Date: 6 ° SignatUre: <br />Printed Num: 4- 44 0, • <br />WARNING: FAILURE TO SECURr WORKERS COMPENSATION COVERAGE IS UNI.AwFuL, ANU SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL Pr.NALTIES AND CIVIL-FINES UP TO ONE HU NrinED THOUSAND DOI.LARS <br />($100.000.), IN ADDITION TO THE COST OF COMPENSATION. INTEREST, ATTORNEY'S PEES, ANI) DAMAGE'S AS <br />PROVIDED FOR IN SECTION 3705 OF THE I.ASGR GO <br />(G-51 licensed authariaed representative). hereby <br /> <br />orize <br />to sign tills San Joaquin County Well Permit Application on my behalf. I undstrstind is authonsetion is Valid for <br />one 1) ear and is lindted to .the work RIKLdated on ths trons_pane of this applicabon. <br />Carrier: <br />Policy Number: Ct-i)6C)