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RPR-06-2001 16:33 FROM PRECISION SRMPLING TD 15592647431 P.01 <br /> San Joaquin County Environmental Health Services, Unit tY Well Permit Application Supplement <br /> JOB ADDRESS: 24457 3. &WU RA., ��� PF-RMrT Ste: CAI <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9 (corrwmcing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in Pill force and effect <br /> License#:_ 3��3 Sr-) Expiration Date: f / S/ 460 y <br /> n <br /> Dabs: `f 6 1 Contractor: lore c, s i on S,x"1) <br /> Signature: 22 Title: l S S meX{ <br /> Printed name: <br /> WORKERS' GOMPENSAT1ON DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to se-if-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 /> 26 have and will malntaln workers'compensation insurance, as required by Section 3700 of the tabor Code, <br /> for the performance of the work for which this permit is Issued. Nty workers'compensation Insurance <br /> carder and po ky numbers are: <br /> Carrier. G, z rT �f Jf✓•/ s u Policy Numbof: �G I 13 o Z 3 3q a/O <br /> I cerllfy that In the parfonnanre of the work for which this permit is Issued. I shah not employ any person in <br /> any manner sa as to become subject to the workers'compensation laws of California and agree that If I <br /> should become subject to the wr rkers'eompemsation provisions of Section 37W of the Labor Code, I shall <br /> forthwith comply with triose provisions. <br /> Date: O) Signature: % <br /> PrintediVarne: �5� �-r /JC�.9✓� <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIFS AND CFu1L FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (b10D,00D.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR W SECTION 3705 OF THE LABOR CODE. If <br /> I` I <br /> I <br /> tsiynature ofC-57 Reensed authorized mprosentadve), <br /> hereby auth Intnarrpl rejwe:-c.Mtietfiye 6taraafrix C&Mts .ta lts, Inn . <br /> . to sign this San Joaq uln County Well Permit Atipllcarion on my behatf. 1 undafatand this auttwdzatlon is valld for <br /> one(1)yea and is limited to the warir plan dated on the front page of thes application. <br /> 5-17-200D/MI <br /> Post-W Fax Note 7671 pale 4y 6 0 ries► i <br /> FPh.I.Ee <br /> Q.R <br /> # r Phone# TDTPL. P.02 <br /> Fax m <br />