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PAGE 07 <br />PAC;;* 03 <br />09/19/200i 03:46 7073745677 <br />00/15 /2 001 11:48 209 -579 -2225 <br />WOODWARD DRILLING CO <br />MODE5TO ATC <br />San Joaquin County Environmental Health Services, Unit IV Weil Permit Application Supplement <br />JOB ADDRESS; atoc At/e-nc.‘e PERMIT SR#: <br />LICENSED CONTRACTORS CONTRACTOR.S DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions.of Chapter S (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is In full farce and effect <br />—a az <br />License #: <br />ly <br />...1 1 -I f "" Expiration Date: 7 ,3 1.„,- eoc),Z, <br />contractor: .SA)Q01,1wiceo oraLLLINs. <br />signature: Title: ()ArveffriO4-IS P)A0J/444frg. <br />Printed name: traessr,e0 <br />WORKERS' COMPENSATION DECLARATION <br />t hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />have arid will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />S- I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers compensation insurance <br />carrier and poky numbers are, <br />Carrier; 57'A1'e Policy Number: <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compansaUon provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: 1-IS w 0 I Signature: <br />Printed Name: _67e4e, cv ie5s <br />WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COYSRAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL. PENALTIES ANC CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100,000.), fN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> <br />4:IPA foes57-4420.01 <br /> <br />(C-51 licensed authertled representative), hereby <br /> <br />authorize C4a)g.t.e CA>1%%0 e424.“ <br />to %ion this San Joaquin County Well Permit Apollcsdon on my behalf. I understand this authorization Is valid for <br />one (1) year and islimited to the wt;iric plan Osted on the front pale of this application. <br />547-2000 MI