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San Joaquin County Environmental Health'Services, Unit IV Well Permit Application Sup. <br />B ADDRESS: <br />JOB ADDRESS: 11 hi wilsoi toy PERMIT SR#: 0.316) <br />LICENSED CONTRACTORS DECLARATION (LCD) <br /> PERMIT SR#: 02 iqs 0?'Y <br />I hereby affirm that I J4PgAlak,11P9Npl-roRvAisgni.s°of DECLARATION (LCD) <br />l apter 9 (commencing with Section 7000) of Di <br />3 f the Business and Professions Code and my license is in full force and effect. <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br />LicP ffie Business and Professions Code) and my i textPa4oir9 fjM).rce and effect. <br />Printed name: ION <br />Expiration Date: 04/30/2001 Da eticreas.ak__ 51 7268 Contractor <br />Contractor spertrum EtWeoration._ Inc <br />/ <br />ittei4ratEture: <br />61 <br />Area Manager <br />rgAure: Sig <br />Pri Title: <br />WORKERS' COMPENSATION DECLARATION <br />h reby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />IllitK@bdrAffA liqMAIRnAr9tfPcearinfoa7nosfg <br />tfoolslo:i duercellorar tions: (CHECK ALL THAT APPLY) <br />workers' compensation as provided for by <br />Section 3700 of the Labor Cod f I have and will maintain a c@rtiP4eeoH6fr9SElf‘PU@ecOittailiescfria- foorittrievonivmitiN, pAeRyided for by <br />7Labor Code, for the performance of the work for which this permit is issued. <br />I havPVE MR IrWai of maintain workers'compensation insurance, as required by Section 3700 of the Labor,Cq,cle <br />for thr t_FArfosh-Nrierrasi #G6.49fswbfftwisaltienniTitiglsvive as peNotifveysstrewo.T&stic3cittwsARr <br />e <br />uoue, ' <br />c4CAPila WcYrrcl Arcework for which this permit is issued. My workers' compensation insurance <br />Carrier: <br />carrier and policy numbers are. <br />nn°ott §ny <br />ulcif t.R 1E4'4 ge€1@,, II*411 <br />DatJ <br />Date:1101U U Signatu <br />forthwith comply with those provisions <br /> Signature: <br />Printed Na <br />dme: <br /> <br />Printe Narrre. <br />Policy Number: <br />C a rrier: Superior Policy Number: WSN i79 8-A <br />certify that in the performance of the work for which this permit is issued I s <br />orthwAbgortgiyoffithstwaisetrirctOilt itipers' <br />rrlikrft?Fyq1E1615rithitleparrifoensalrbleelftbIttili*diEke4411 14i t-JVA '6'6' ,h5 I' agibf <br />hou IA flA-QiiihleSitbjest tta) ttheoititUUtfEtettotiEh c:-Ir '_! <br />pen <br />orcd4PISR 4'' q6i) tion provisions or e ti, n <br />WARNING: FAILURE TO SECURE WCI <br />AN E vismtartar6TOMMINIVNA4 <br />($100 0611.prtfleaDiNfi6f4 qt31 Prii- <br />PRovictiociim.PAtUlarfat. <br />PROVIDED FOR IN SECTION <br />a • ' • Wccria/ bitkORPOI,Patesmaxill_ SUBJECT 1. .1 , JPRAMiittoliamornolaumrtimatamok§ <br />:I" 1-• db1,1i§litE-PffsIVATiCi5NerY3TEEIE$AMIPEVAIW§g§ A§ <br />V:71 ALN)DE. <br />givoc.genar1148%bY <br /> <br />authorize • <br /> <br />au • WAS ) (consulting), to sign this San <br />to sigll tNs cfn Apoioptidnidn inapciAmtanditbiadtkAviVetisig RARIblicRiSilleiM6arfor <br />one (11) Una( arifitrificlifriiMet9AR eiiNkcittida ciatbd bnrdieafrtftf Oti§eleltfAiiibplication. <br />• <br />Sep 18! cif : 08p --.trum Exploration, Inc ' 465-8773 p . 2