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07%13/2004 14: 22 20946527' SPECTRUM EXPLORATION PAGE 02 <br /> • <br /> San Joaquin County Environmental Health Department Unit iV Well Permit Application Supplement <br /> JOB ADDRESS; �n Po 4�ce-t `��J`��i° <br /> PERMIT SR#: <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#: 512268 Expiration Date: 4/30/05 <br /> Date: ? 13 Contractor._Spectrum Exploration, Inc. <br /> Signature: Title: Operations Manager <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 /> 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 /> Carrier:_National Union Fire Insurance Co. Policy Number: 6436303 <br /> 1 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'com ensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: -7 13 )04 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 CML 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 /> T ORIZAT N FOR OTHER THAN C-57 SiGNING PERMIT APPLICATION <br /> I,_Bran wford,of Spectrum Exploration,Inc.—(signature of[C--57 licensed authorized representative), t 1 <br /> hereby authorize(print name) r `l T , ct ) t .l n SC,( W-S I <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 />