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Aug 16 01 03: 14p WEW-X <br /> [91$373-0548 p• z <br /> 85/15/2000 e8:21 2094983433 FIFTH FLOOR PAGE 03 <br /> Sari.�Q,a9ufrtL`oilhEy:'Enkimrunet4ta�,+.iaa111hSetKlcc • uPplemlM;-.;�,i <br /> s llnrbFY We11 PemlftApph4�ronS <br /> JRB JLdCiLS <br /> j1RC0 6A'S STATION @ PERMIT SRS <br /> • � ..:' ``' 'patterson' Road; TY:Acy; 'CA <br /> :.. . ..., <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 3 ofr <br /> rthe Business aand Professions Code and mysions licensefis in futer 9 (commencing ll force and eftectt.with Section 7000104 Division <br /> License#' <br /> 057-552198 EXpliahanOuts: 06/30/03 <br /> Date: 08/16/01 !/ Contrac <br /> WESTE STRATA E 0 <br /> Ttae:_General Manager <br /> Signature: - <br /> printe name rdon/D. Jensen J <br /> / WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declareVoris: [CHECK ALL THAT APPLY] <br /> I have and will maintain a certificate of cOns�arsel of the work torxer which rnP8ns flO s,issued. <br /> XX <br /> for by <br /> Section 3700 of the Labor Code,for the pe <br /> XX I have and will maintain workers'compensation insurance,as required by Section 3700 oof theLabor Code, <br /> for the performance of the work for which this permit is issued. My workers tampon <br /> carrier and policy numbers are: <br /> Carrier: <br /> State Comp Insur Fund Policy Number. 1569784-02 <br /> XX 1 certify that in the performance of the work for which this Perm tioit n laws sued,I shinpensICalKdna,and agree l not employ any person in <br /> any manner so as to become subject to the workers' cors <br /> should become subject to the workers'oDmpensartio rovjsrons of Section 3100 ghhe Labor CRoe,I shall <br /> forthwith comply with those provisions. <br /> Date. 08/16/01 stwulture: <br /> Gor o <br /> • printed Na :` .- <br /> WARNING:FAILURE TO SECURE WORK �EONIPENSATION COVERAGE� IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRINUNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> / IN N ADDITION TO NE OFI E <br /> STFLABOR COMPENSATION-INTEREST,ATTORNEY'S FEES,AND DAMAC+E9 AS <br /> SECT <br /> PROVDEO POR <br /> 1 I. <br /> Gordon D. Jensen Jr. (C-67 licensed aurhorizad repnasentative),hereby <br /> authorize Stratus Environmental - <br /> 1 <br /> Well Permit Application on my behalf. t understand this authori t;on Is valid for to sign this San Joaquin County P <br /> nc 11 I Year ono rs limited m the work n dared on the front Page of this Iioation. <br /> 70 39tid ON Sflivai5 S0099L90E9 bE:£i I00Z/91/B0 <br />