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09/06/200'.7• 14:53 2094658773 <br /># <br />PAGE 02 SPECTRUM EXPLORATION <br />4S/-1 <br />San Joaquin <br />County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: Y • PERMIT SR#: .0579W <br />LOcek) c 1s?(-10 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />Expiration Date: 4— 3 0—P 9 <br />Date. Contractor: Spectrum Exploration, Inc. <br />License IP 51 2 2fi 8 <br />to-01 <br />Signature: <br />Printed name: Brenda Crawford <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />_ X 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 policy numbers are; <br />National Union Fire <br />Carrier: Tricllt.an rP rrttiparl y <br />Title; Location Mana <br />WC 159 3164 <br />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' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith corriply with those provisions. <br />Expiration Date: 4-1 —0 8 Signature: <br />Printed Name: Brenda Crawford <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY's FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature ofC-57 licensed authorized representative), // <br />hereby authorize (print name) <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-02 MI <br />79-02-Cei