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<br />07/11/00 TUE 10:33 FAX 1 916 861 0430 SECOR-SACRAMENTO <br /> <br />Z002 <br />FAX NO. : 191E638E513 <br /> <br />Jul, 11 2000 07: 44AN P2 <br /> <br />07/.10/00 MON 18:58 FAX 1 918 861 0430 <br /> SECOR- SACRAMENTO <br />Z 014 <br />0 4 /28/2000 EIP!22 269462,3433 <br /> rr• <br />PAGE 04 <br />Sfiii4p4qeIn:copentyEn.virentnentallfaaltrt 'tea:: UtikrVWfiltil:Iorrn 15 atiiiiti. <br />..'igtiii,107,0**/6(0- 5.r,,•i-t. t2-041: ::. 'F.i:Fiii42t ,..Sttiff., DO 547,6, 6 <br /> <br />.. . ,401- .).-- ' :, 2 Li 1-616--:b 4 <br />13 t:cs s St,....),....€•‹. <br />2- Z 3 701 S Caorkia Fr <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby atttrrn Vial. I am liCensed under the provisions of Chapter B (commencinq with Section 7000) of Division <br />3 of the fiusiness and Professions Code and roy licnnea is in ferns 2nd effect. <br />License #: 5 5 q 7 q_7_ Expirittion Date: ° / <br />Qgte: - 10 - C, 0 Contractor: 1:ies (Inv- p nv- <br />Signatural ,c--"/a p--/ roe: TVID , 6Ab4t-- /14,14 Ii"-' <br />Printed na Ic44-ere6A0 14, <br />WORKERS COMPENSATION DECLARATION <br />liereby affirm Under penalty of penury one of the following &Aerations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to aelrinsure for woricers' compensation. as provided for by <br />Section 3700 of the Labor Code. tot: the performance of the work for vvhich this permit is issued. <br />_ZiaVel and Will Maintain workers' coMPerlsation insurance. as required by Section 3700 of the Labor Code, <br />for the perfo7nancs of the work for vitadi Di perMit isduect.Myworlui compensation insurance <br />carrier and policy numbers are: <br />Ca rrier:4-----rp-A1-4-4-Th• <br />./(certify that In the performance of the work for which this permit Is1544,Jed, 1 shell not employ any person In <br />any manner no as to become subject to the work:err.' compernsetion lawf, of California, and agree that If I <br />should become subJeol ta the <br />workers' compensation provi$Ions of Section 3700 of the Labor Code, I shall <br />forthwith Dorn* with those provisions. <br />Date: 0 7 6 ° SignatUfs: <br />Printed Nemo: r--141"rn-rt ' <br />WARNING: FAILURE TO SECURe WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AM.) sNALL SUBJECT <br />AN EMPLOYER TO clkIMINAL PINALTIE5 AHD CIVIL FINES UP TO ONE Hu NottED THOUSAND DOLLARS <br />($100.000.), IN ADDITION TO THE COST OF COMPENSATION. INTEREST, ATTORNEY'S FEES, ANL) DAMAGES AS <br />PROVIDED FOR IN SECTION 370 OF TEE LABOR CO <br />. L., .- s <br />(c-6.1 licensed authorized representettYe). hereby <br /> <br />oriz, _4,4ns- A c6.4ner, e-c <br />to sign thla San Joaquin County Well Permit Application on my behalf. I understand this aughonzetiOn io ValId for <br />ono 1) ear arid is iirtittatd ta .the vigor% plan dated on the front page of this appiication. <br />FROM : West Hazmat <br />Policy Number: /12 / %/6/1-li4 1 cLL-