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Rug 26 02 10:42a <br />Spe0um Exp. <br />San Joaquin County Environmental Health Services, Unit IV <br />209-1$-8773 p.2 <br />JOB ADDRESS: PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 0 (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 k. C57# 512268 Expiration Date: 04/30/2003 <br />Date: Contractor: Spectrum Exploration, Inc. <br />Signature: Title: Operations Manager <br />Printed name: Brenda rawford <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penally of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I 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 />xi- I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Code, <br />for the perfomlance of the work for which this permit is Issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Caller. American Motorist <br />Policy Number: 3BG03575800 <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 it I <br />should became subject to the workers' compensatio4prav ons ofSection 3700 of the Labor Code, I shall <br />forthwith Comply with those provisions. <br />Date: g1�ioA2— Signature: <br />Printed Name: Brendaford <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100,000.), 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 />I tiret <br />rawford of Spectrum Explor <br />lure oIC-67 licensed authorized representative), <br />hereby authorize (print name) IQilU h(LUl((I Ut t CI B IYi <br />to sign,thla 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 />6.17.20001 MI <br />