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DtL-14-2001 11:5 FROM PRECISION SAMPLING <br />TO <br />19168610430 P.01 <br />San Joaquin Cotry Environmental Health Service% Unit W Well Permit Application Sof*!Orient t <br />El ADDRESS: -1'SliC/I,EAK uoti PERMIT SRft: <br />UE.0 <br />-T:rotAi Gig k) <br />I hereby affirm that am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my 1i067)5g is in full force and effect, <br />License 4r: S 6 3 ?*- Ti Expiration Date: <br />Date: /2--/i Contractor: iqr 7 <br />Signature: <br />P-y-Q Printed name: <br />WORKERS' COMPENSAIION DECLARATION <br />I hereby affirm under penalty 01 Perittly one of to tallowing declarations: (CHECK ALL THAT APPLY) <br />1 have and will maintain a certificate of consent to soli-Insure for workers' convert sabon, as provided for try <br />SOCItOr 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> have and wiP maintain wokenV compensation instrance, as required by Section 3700 of the Labor Cods. <br />tor the performance of the work for which this perrn;t is issued My workers` compensation insurance <br />canter and ley numbers are: <br />Carrier: (-:6c,r4--1 bt-e ulu / Palmy Number: 6-)C-' 67 / 7 Z-3 3 - 01 e) <br />I certify that in the performance of the work for which this permit is issued, I shall not errIploy any person in <br />any manner so as to become subject tG the workers' compensation laws of California, and agree that if I <br />should become subleci to the workers' compensation previsions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those proVisions. <br /> Signature: <br /> <br />Printed Name: <br />WARNING: FAILURE TO SECURE wORKERS COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENMXIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100,000.) N Avornom TO THE COST OF COMPENSATION, IIITEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 37D5 OF THE LABOR CODE. <br />(sInnature 0047 licensed seMorized representative), <br />hereb notirtgriza (luitItnerwle) 11.1-"L‘zg Lf .5 SW, <br />to sign this San Joaquin County Well Permit Application en my bet-..V. E untiasttuul this authorization Is vad for <br />one (I) year and Is limited to the work plan dated on the front ono of 1:11111 ePPlicallan• <br />5-17-200011AI <br />ENVIis ,-n ."\ALNIa ' <br />LICENSED CONTRACTORS DECLARATION (LC,py pERmii/SER <br />Wel ( /It sc 6 <br />J1 <br />ICES <br />/ y <br />(570) z 3 7 -