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04.17%2006 12:49 FAX 71493967- TESTAMERICA DRILLING Ia001 p,,© <br /> A 4.4R ced Geoh viro�mental No. 45'�' P, 2 <br /> San Joaquin County Env1mnmP_nt;1I Health Denarfmant IInit rJ Wan Parmlt Applirafinn Supplomont <br /> JOB AppRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION ( , D} <br /> a <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing wkh Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect <br /> License#: a/7.s—Y EVIration Date: �- <br /> Date:_Y- /7-O4- Contractorf /e3►►^ /Q�►Cn.l��► , .tc.�.w.� fi.lr'Si/T ,rt <br /> Signature. Title: 45�7&eA4t Sb� <br /> Printed nametc If !�✓Ip r �M� <br /> WO RS' COMPENSATION DECL'A' RATION <br /> I Iiviouy afflnn ufitler lLerraity of paqufy one or the rollowng nealaratlons: (GHEGK QNL) <br /> I have and will maintain a certificate of consent to self-insure fer workers'compensatlon,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> V I have and will maintain workers'compersation insurance, as required by Section 3700 of the Labor Coda, <br /> for the performance of tha work for which this permit is issued. My workers'compemsa;ion insurance <br /> carrier and policy numbers are-- <br /> Carrier- <br /> re:Carrier:�r R�f`(�� �N.S .�Policy Number: Zz.. _W 6al,4M '7/31 <br /> I certify that in the,performance of the work for which this permit is issued, I small not employ any person in <br /> any manner so as to became subject to the workers'compensation laws of Caiifomia, and agree that if'] <br /> should become subject to the workers'compensatlon provisions of Settlor;3700 of the Labor e, 1 shall <br /> forthwith comply with those provisions, �,Jf <br /> Expiration Date: 04-6/:,d' -Signature: L/ f <br /> i -d <br /> Printed Nam : i c-c�A*t.� n <br /> WARNING:FAILURE f0 SECURE WORKERS'GOMPENSATIpIV COYEf2AGE 1S L,ANb SHALL SUBJECT <br /> AN EMPLOYER TO CRIMIkAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED OUSANO DOti.ARS <br /> ($100,600),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,AITORNEWS FEES,AND DAMAGE=S AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 /GI /Is7�.0 " ' _ I + f' r (signature ofC.67 ficensed authorized repreaentaU e), <br /> hereby authorize(print name) 81.51 <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization k valld for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> B-29-421 MI <br /> E913 29-02-001 <br /> 6122/04 <br />