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0 • <br /> Da,/29/05 WED 11'33 FAT 5592715108 SECOR f?1002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 508 Charter Way Stockton PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 8(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Cade and my license is in full force and effect. <br /> License lit:636387 Expiration Date; 1 /31 /06 <br /> Date; / 05 Camrector-Precision Sampling, Inc. <br /> Signature: C. ��G2*%�Yr Title: C1,'b,CTt .Y <br /> Printed name: Oe'o' WLFKAKEIz <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dodaratiorsr (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-Insure for workers'compensation, as provided for <br /> by Sector 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. <br /> g„I have and will maintain workers'compensation Insurance,as required by Section 3700 of trio Labor Code, <br /> for trio perforrrmnre of the work for which this permit is issued. My worker;'compensaton insurance <br /> carrier and policy numbers are: <br /> Carrier. Liberty Mutual PoiicyNumber: WC2B710723390285' <br /> I certify that in the performance of the work for which this permit Is Issued, I shall net employ any person in <br /> any manner so as to become sub)er1 to the workers'oompensetion laws of California, and agree that if 1 <br /> should become sulci to the workaro'compunsahon provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply wtltr those provisions. <br /> Expiration Date: b/ 06 Signature: <br /> Printed Name: ILly W <br /> WARNING:FAILURE TO SECURE WORIMRB'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,01)(1.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORI TI N FOR OTHER THAN CS7 SIGNING PERMIT APPLICATION <br /> (Signature <br /> Q1C 1T Iloansai authorizad repmsont Avo). <br /> hereby AuthoriAe(Print name) KKY �U(7r�A.PQ-u ✓GGCI'� 1 .�1RZ( � <br /> to sign this Sen Joaquin County Well Permit Application on my behalf. 1 understand this authorization Ia valid for <br /> one(11 year and Is limited to aha work plan dated on the front page of this application, <br /> &29-021 MI <br /> am 29-02-001 <br /> 6P-110i <br /> .JUN-29-2005 10:31AM FAX:5592715108 ID:PRECISION SAMPLING PAGE:002 R=95% <br /> ?'d 80TSTL26SS:01 bLSb 122 OTS FNI-ldl, S NOISIDEIdd:WOdd SO:£T 5002-6Z-NOP <br />