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03/19/1995 20:54 916-961-1773 WATER WELL TECH PAGE 01 <br /> 04/04/2001 15'24 20953® GEOLOGICAL TECHNICS PAGE b1Illi <br /> d8/e2/2t7Q0 09:42 2094683433 <br /> FI1=714 FLOOR <br /> Unit IV parrltit APA at nn uO <br /> San Joaquin County tnvironrnenlsl ttlrservtase, Pk fT <br /> j0B ADDRESS' �l <br /> trICEN <br /> SED CONTRACTORS pECLAPAT04 (LO) <br /> S aarrxnerlclnq►Nitht Section TODD)of Divlsfan <br /> I nerer,y�iflrm that t am licensed under tho provisions Ot ch&Pte 14(0 end effect. <br /> 3 e the gugfness and professbns Code find my tfaensa Is In Ni <br /> l 10rcs 11 11cplrarti0n Data:ter. <br /> License 0, <br /> _ d or. <br /> Oatd: Title: <br /> Signature. <br /> printed nsrne: <br /> WORKERS' COMPENSATION OEGLARAMON AT APPLY) <br /> hereby aff��rn under pGneity of perSury on*of ttte'PotlOwing <br /> daol*rativne: (CFlECK ALL THAT <br /> i rrrit is issued. <br /> I t have and will maintain a certirlcate f o ns�o s ev work torr wilrilCit flits�orkwi stlt!an,as provided for Y <br /> Section 37'00 of tre Labor Code,fort P aged by$ecti0t►3700 of the"elnor Cade, <br /> tyasdon insurana6,04 rw wQ bq 8 �Pa7�bon insurance <br /> I haft and will maintain aorktr9 Gomp�e Is �µpd. y <br /> for the periorrnance of the Werk for wtllch this p <br /> carrier and poltcy numbers ale: ,)- 11;1�2-11 <br /> Q ,1��PnliCy MUrttbN: <br /> Carrier= {}�� s�� fill erion In <br /> mance of lhs"rk for wtriGh tMla perrn►T Is Issued;l sltlallU npt errtptoY a and ree that it I <br /> anymann•ciao as to become sub)W t0 the workers'�mpenQetar n �n�00 o he t.&,,cr Cods.I shalt <br /> should boCo�sub)ect to the workers'wmp4r�>ystlan provi3igni Of <br /> forthwith comply with those proylalont, <br /> 1 Slgnature: <br /> Date, <br /> Printed Name' <br /> u Arte sH�+u.su�Ec7 <br /> LLARS <br /> WARNlNO:FAILURE TO DeGURE WgRKCaRb'COMPpN$AT1ClN COY Cts iS t,l01NO L. <br /> Qg7 Gf M 01V11�/lTI9N,tNTffptlSBT,ATTARN�E FEES.ANti DAIiAAOLS A5 <br /> AN EMPLOYER TO CRINNNA THE C LTIES Attl�CIVIL.RtN2S Up To'bNE HUNCII�D�{gyBANP DO <br /> (Stno,udn 1.tN AporrtvN TQ <br /> PR R IN SECTION s7 F't'HE LABOR CdDS. <br /> C nY iioensad authot'i r0Prs06n11%"e).hnreuy <br /> l <br /> for <br /> rizaWn Fs valid <br /> authorize . 1 arldentand thM a"Ihc <br /> to sign this Sen Jna9uin County Wrti Permit APpticattOn�MY <br /> ono 0 ear and is 11-112d tv the work tan dated an tl1aC114n! <br /> POOR Of this■ n• <br />