My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
FIELD DOCUMENTS
Environmental Health - Public
>
EHD Program Facility Records by Street Name
>
B
>
BANTA
>
26501
>
2900 - Site Mitigation Program
>
PR0505092
>
FIELD DOCUMENTS
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
2/5/2019 4:58:08 PM
Creation date
2/5/2019 4:46:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0505092
PE
2960
FACILITY_ID
FA0006532
FACILITY_NAME
LYOTH LOADING STATION/CHEVRON
STREET_NUMBER
26501
Direction
S
STREET_NAME
BANTA
STREET_TYPE
RD
City
TRACY
Zip
95376
CURRENT_STATUS
01
SITE_LOCATION
26501 S BANTA RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
WNg
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
162
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
San Joaquin County Environmental He�alth D�ey artment Unit IV Well Permit Applicationze <br /> JOB ADDRESS:<' 353 S /- i <br /> PERMIT SR#: �3"e-e0000 Ii, 3/j <br /> �g 3"s <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#: p z - 3 3 y I / <br /> Expiration Date: <br /> Date: o Z c Contractor: /-SZ <br /> Signature., _ <br /> Title: <br /> Printed name: <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' <br /> by Section 3700 of the Labor Code, for the performance of the work for whicompensation, as provided for <br /> ch 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: She l <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 comply ith those provisions. <br /> Expiration Date: �� �, 0 Signature: <br /> 7'"' Printed Name: <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 /> ($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 /> 1, <br /> */ 1 n PQeL(signatur OfC-57 licensed authorized representative),hereby authorize(print name)_ <br /> t C <br /> , <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 /> EI ID 29-02-001 <br /> 6/21/04 <br />
The URL can be used to link to this page
Your browser does not support the video tag.