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09/05/2002 08:56 2094671118 <br />SEP- 3-02 WED 525 AM 14,13,E. <br />/26/21a02 1E:27 209467111S <br />AGE STOCKTON <br />FAX KO, 9 1,6 852 9558 <br />AGE STLEKTCH ro4,ar- <br />PAGE <br />F 2 <br />San Joaquin County Environme tal ti..?/rte nit fl#311'e <br />1 • <br />I her.by affirm that I am licensed under the provisions of Chapter 9 ia9sTrjr.iRnilsosAtt§prbizzoonRiaiebflDiliision <br />3 of he B4ine„nr744Firipirtfttigockcio wor,isioaatcropq %cup. tleCt. <br />Lice rier.D"Tit Acet -,1 fess°111C414*) and • t (L_,L1 t1-73 <br /> <br />my Iltense is in V] ores is <br /> <br />Es*V8191rttiV. e ' e <br />Date: <br />Sign ture: <br />Signature: <br />printed na—m-a; ift)A Printed name: Fd <br />WCiftbigaSeSCCIDAPENSORAPI5gar*MON <br />I here Ygtigli AlFtiRruii,Nclihtvikpeeilirlutortifcti-kli6f16461 ElgfRenosi:;s(C rgtC'kLAIY_A-;IHALPLAYPPLY) <br />Pre'vipreocjvidorebdyfo by -,..t pstiikvilhot-pgrmittatnnteksuptiFegig8T tnNicliess_etIns we fqr wcricers' compensation, As <br />S atiore430:13145' f&coL*14344eck?Sitr IfillIDWrforrrna8n5ce grgheCt.W6o"trrrilVfor which this tlfrittii8fIlHi 4!gi3is Cod <br />X\:t I I-• i pirf i gi giiI.ItiteiVriciict,(s' corn p eiramati@anoinst:;11nos ,usisil: e qu imre:lbsy Section <br />fliSi416 iitiffenteabor 'Co e , <br />SACN - i_u <br />u9141(9qca <br />rs arr <br />p. r whi h this permit is issued. My workers' compensation insurance <br />.carrier 5A <br />,fo the KIOR 51r, <br />Carrier: <br />Carrier: c 74- nitAi Pciiicy Number.: _L-5:13,1162-171 71 7- 0 - <br />K t I certify <br />that In the performance of the work for willch inls per 1 In rbSvfw, , shalt --• --•-•-• - • , raci.n in <br /> I cOrtint ilkOrtfrl Oa periagniarl7Strig$M th51, k ‘ . risatn taws cef California, arid agree lhal r I <br /> Pocy,Nuni,koz:, A i nAT omnlov aro/ De <br />, r "n any mailhooldatietorrielid404cACI,jeat ileo 8T ers f'dApentaltiOrnit4s4b7123tICal:t-litInia4,"51cand agreethatfl <br />sh uld berdavittb mtliAtte481 44T4ciirP4N D rc` dm pensation provisions of Section 3700 of the Labor Code, I sh II <br />forthwith comply with those provisionpature: s, <br /> <br />Dale: zi <br />Date: i <br />wARNING: FAILURE To PitrePEIARTIIIIIRs' CPMPENSATION COVERAGE15 UNLAWFUL, AND SHALL SUBJECT <br />N YEA TO CfiIIMINAL PENALYI5S AND CIVIL FINEs Ur, i 0 ON! MUNDRED ThICLISANO D. LAII3 <br />§,ITgb§ffatiftlIIINCRI4IMSP <br />SAT ETTISORLINNEYLA'SWFFELS: <br />ANDAN HA D CISAMALG WARN!L SUILBJE T <br />AN EM LEJN faontittuvemAti:rits Itild,6 O O <br />($100,010.), IN ADDITIONTO TH COST OF C PE4ATI N U; <br />TTERENSE HUNDREDT,ATTORNEYTAN DOLLARS <br />FEES, AN <br />N <br />ft! FOR I *?7 ?flih pDE. (C-57 lIeensalgolgaiWUP <br />signature ofC-57 liceosetc;;;Ipfltir:%11711079:11115tSa2tniv <br />hereby utifergilri6RIffitrinartrm ip,p11.01.7onj on my kienall__I understand this authorize on <br />v <br />to sign t Iserg is limited lo te work plan dated on'ths front page o <br />an JOaquin County Well Permilajanlif.af inn fliFI4Y-19(thalf--tunctergis authortion is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />1-25-02 / MI <br />Jo <br />40B AD,RqS.1_2, -Irixa---1 14A- i4D 4.14,!:!.0 <br />u uRS DECLABAD <br />LICENSED CONTRACTORS DECLARATiomCnigr_ <br />CD) <br />LiCansik tr. <br />Date <br />••••••-•,••••••••• <br />PROVI <br />authorize T