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SR0024641
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2900 - Site Mitigation Program
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SR0024641
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Entry Properties
Last modified
5/8/2023 11:13:44 AM
Creation date
4/24/2023 2:10:55 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
RECORD_ID
SR0024641
PE
3501
FACILITY_NAME
MINI-MALL, OFFSITE FOR TOSCO
STREET_NUMBER
16460
STREET_NAME
CAMBRIDGE
STREET_TYPE
ST
City
LATHROP
Zip
95330
APN
196-430-15
ENTERED_DATE
11/22/2000 12:00:00 AM
SITE_LOCATION
16460 CAMBRIDGE ST
P_LOCATION
07
P_DISTRICT
005
QC Status
Approved
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SJGOV\bmascaro
Tags
EHD - Public
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11/15 /2 000 13:54 19166335611 <br />CASCADE DRILLING INC <br />PAGE 06 <br />t7:7F17., <br />- dev: <br /> <br />7.: • ii77:47" ••••-'4 <br />LICENSED CONTRACTORS DECLARATION (LCD) P411 . (#9 <br />I hereby efirm ttiat IBM kenswi urraf the prvAsiora Cr! Chapter 9 (cornmencing with Becton 7000) of DIVIII100 <br />3 of the Ehmlnete Snd PrvfessIona Code end my license is In full force and effect. <br /> <br />Expiration Dela: — 31- <br />Date: )1-1c -0 0 tractor CC ci Dr <br />Sign attire: Title= op_c_, Mjr• <br />Printed name: era_ _cd <br />WORKERS' COMPENSATION DECLARATION <br />hereby sfin-n under penalty of pedury oce of the following declarations: (CHECK ALL THAT APPLY) <br />I henry end will maintain e certificate of coneent tole/Of-Insure fcir workers' compensation, se provided for by <br />Secton MO of the labor Code, for tie berformsno• of the work for Which Vita permit 19 lasiArd. <br />have and wil maintain workers' ccrripensebon insurgence, as required by SectIon 3700.of the Labor Gode, <br />for the performance of the work for which this perrntt Is issued. My workers' compensation Insurance <br />cerrier and policy numbers are: <br />c. N aijocw <br /> <br />Polley Number: 00G-W5_a_p_531 <br /> <br />I cent/ hist In the perfonmance of the work for wtlich IN: permit is !saved, I ahmil riot employ any person In <br />any manner so as to become subject to the workers' compensation Lew; of Caiifornte, and were that WI <br />should become subject to the workers' cc mpensation proVIsliIfT Section 3T00 o1 the Labor Code, I shell <br />iorthwrth comply with those proirksions. <br />Oat.: 1 —0 0 Signature: <br /> <br />Prints(' Nemo: e _ NCO._ <br />WARNINQ FAILURE TO BICURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, ANO SHALL ISUOJECT <br />AN EWLOTER TO CRIMINAL PENALTIES AND CIVIL FINE8 UP TO ONE HUNDRED TNOLISAND L'JOLLAIRS <br />($100,00O.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S.FSES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3709 OF TIIE LABOR Copt. <br />(signature otO-S7 licensed authorized noppresentstlw), <br />hereby authoorlie rlarne) <br />to ;In this Son Josiluln County Will PerrnIt Ape/lc:eller on my bailiff. I understand this IlSialartiatie41 Ia vend for <br />une pier end is limitsd to the wort( plum dirtyd ,on Me front pegs of this applIcadoo. <br />5.17-20001 Ml <br />, 01, 6 f g_, o 07Jko( <br />License it 71-7-Ci 0
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