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Bin]corintyErivironinantaliisalth Service U <br />PRMLT's <br />"frif4xire 4 :- <br />LICENSED CONTRACTORS DECLARATION (1,1Qp) <br />I hereby affirm that I am limnsed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 or tne Business and Professions Code an.d rnY iicerIbe is I^ fun fCirCk' and effect <br />FROM : West Hazmat <br />FAX NO. : 19166388613 Sep. 19 2000 04:16PM P1 , <br />JA1/1918 me52 FAX 1 916 861 0430 <br />64/28/2000 188:23 2R94603433 <br />SECOR- SACRAMENTO <br />FIFTH FLOM <br />Ij 001 <br />PAGL P4 <br />License <br />Oat: COntract01.: <br />Signature: <br />Printed nam <br />Expriation Date: /- 5 / - 0 I <br />dee r. • -3'. 0/2- l42&— — <br />Title: Petit - <br />rs-Licy 77 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm uncle" penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will muintain a certificate of consent to self-insure for workers compensation, as provided for by <br />Section 3700 of the Labor Cede. for the performance of the work for which this permit is issued. <br />1 I have and will maintain workers' compensation insurance, as required by Section 3700 cif the Labor Code, <br />for the performance of tho work tor which this permit is issued. My workers' compensation insurance <br />carrier arid policy numbers are: <br />Carrier: / 72A,Akce-LIAS /4 i3. Policy Number: FV36 1-rw6 SSigdczli ott' <br />I certify that in the performance ot the work for which this permit IS 1661.1ed. I sheIlonmaoit.employan ug aarerz <br />that <br />perswl In <br />any manner so 3S to become subject to the wurkers' cornpeneation lawa of Calif <br />should become subject to the workern' compensation provisions of Section 3700 of the Labor Code, I shell <br />forthwith comply with those provisions. ____--- - <br />Date: ° 7 - I 7 --6—L Signature: <br />Printed Name - <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN FMK-OVER 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 j HE LABOR CODE_ <br />r_.<77tideedii•° 011-4-'ca-IH-r- (C-57 licensed 2uthorized representative), hansby <br />euthorize dr;b/YEIL_____14 1-/;1/7- Z4g____5 <br />to elan this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />eine (1) year and is limited to the WOrk plan dated on the front eage of this applleatidn.