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tks Contractor: Oate: <br />Title: OXAMONS ,f24PJ.4elP6ie. Signature: <br />3/19/2001 OS:48 7073745E77 WOODWARD DRILLING CO PAGE 11 <br />a8/15/2001 ii:48 209-579-2225 MODESTO AM PAGE 03 <br />lit44)/i tef <br />r San Joaquin County Environmental Health Services, Unit tV Well Permit Appilcation Supplement <br />1 JOB ADDRESS I4 44 /f-e-a-L‘-e_ PERMIT SRM <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that WTI licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Susiness and Professions Code and my license is in full force and effect <br />0o79 EvPirstion Date: 7- a I Zoc.)42. <br />1 <br />Printed name: 6ie14. eradeSs nect <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations; (CHECK ALL THAT APPLY) <br />I have and wilt maintain a certificate of consent to seif-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 />I have and will metita4n, 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 policy numbers are: <br />Cartier: •71 AT'e poNo Policy Number: (DO ao23 e? <br />I certify that in the performance of the work for which this permit is issued. I shall not employ any person in <br />limy manner so as to become subject to the workers' compen.sation laws of California, arid agree that if <br />should became subject to the workers' compensation provisions of Section 3700 of the Labor Code, I seen <br />forthwith comply with those provisions <br />Date: 41'w/8'CA Signature: 2;1 <br />Printed Name: Cepe. Aciide,sf FAT:owl <br />WARNING: FAILURE TO sEcuna WORKERS' COMPENSATION COVERACE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />00,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES As <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR 000E. <br />I. 6ei.e. A14557-412001 <br /> <br /> (0-57 licensed authorized representat)ve), hereby <br /> <br />suthortze ae..04Ge _ eltio1/41U0e—Se. <br /> <br />to .In this San Joaquin County Well Permit Application on my behalf, I understand this authorization Is valid for <br />one (1) oar ard Is limited to the work pltri datorl on thifront page of this appllestlort. <br />1.11-2000