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Oct. 23 2001 18:11M P1 <br />PAGE 02 <br />FAX NO. : 19166388613 <br />AGE STOCKTON <br />FROM : West Hazmat <br />[!! <br />'1 1P3/ 2001 08:b4 205 1118 <br />San Joaquin County Environmental Health Services, Unit IV Well Penult Application Supplement <br />JOE3 ADDRESS: 231,5-1 PERMIT SRA: <br />AVIle120 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />htirehy affirm that am licensed under the provisions of Chapter 9 (=Mending with Section 1000) of Division 3 of the Susiness and Profes3ions Code and my license is in full force and effect. <br />License s-sY, -75 <br />Date: /D - Z-3 -0 / Contractor 4iJér4-14 z."1-4 1441 LA-A 0,a. <br />Printed niamr:: 4.4 *I1-1-4-"4 CV1 <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I Ti and will maintain a canificate of consent to self-insure for workers' compen4ation, as provided for by S 'on 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />have end will maintain workers' compensation insuranGe, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carnor and policy numbers are: <br /> Polley Number: F 2.-Lxgav6 e2.7/ <br />I certify that In the performance of the work for which this permit is issued, I shah not employ any person in any manner so as to become subject to the workers' Compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. <br />1 <br />WARNING: FAILURI1 TO SECURE WORKERS COMPENSAtION COVERAGE IS UNLAWFUL, AND SHALL 8UE1JECT ' AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS )1 410%0004, IN ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNErS FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE L AEiOR CODE <br />14 HO 1144-4-14-?-i-- (C-57 liconzed authortzed reprerentative), hereby <br />OF - &/' Cedt, vi,L4 <br />tO Skin thi San Joaquin County Well Permit Application on my behalf. I undemtand this authorization Is valid for 'one (1) year and is limited to the work plan dated on the front page of thia applloatIon. <br />.5474000 / MI <br />=Q I 11 <br />'t!,b <br /> Signaturr _ <br />Printed Name: (.4,44-71-A0 <br />r. <br />4-Authortze_ <br />Expiration Date: el/ - o 3 <br />Signatur