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�eb� 08 02 09: 46a Spectrum Exp. <br /> 209-465-8773 P. J <br /> �w {s <br /> [JOB <br /> an Joaquin County Environmental Health Services, Unit IV Well t pli , lD element <br /> 4 � . <br /> ADDRESS: 26 5 I Sowt4 A o^r LJ PERMIT SR#: <br /> ' Stoc6rto <br /> ;I <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 /> License#: <br /> tionDate: 04/30/2003 <br /> C570 512268 Expira <br /> Date: .2 ,-- Contractor: Spectrum Ex location Inc. <br /> Title: Operations Manager <br /> Signature' <br /> Printed name' Brenda rawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> have and will maintain a certificate of consent to self-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 /> XX 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 /> i <br /> Carrier: American Motorist Policy Number: 3BG03575800 <br /> _I certify that in the performance of the work for which this pemvt 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'compensatio4prov ons ofSection 3700 of the Labor Code, I shall <br /> forthwRh comply with those provisions. <br /> e/d — <br /> Date' � 4 Signature: <br /> Printed Name: Brendaford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> I AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,Otfo.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> y PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> Brenda Crawford of Spectrum Explor.(signature ofc-57 licensed authorized representative), <br /> K.(2RKj I t�zrd " �hi i• �et2�iC�s Cas '_ <br /> hereby authorize(print name) <br /> P 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 /> &17-20001 MI <br /> �p <br />