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Seo. 23. 2005 9.45AM Advap GeoEnvironmental <br /> .ioaquin Gaunty 5avirattma Qaith6Nr ant Unit ry IlVell PeritlltAppltoa#ion Supplemdn# <br /> rsan <br /> R AppRESS:ST�K�, We I^'. G 2_O�I - PR�VIIT Sf #. <br /> LICENSED CONTRACTORS DECLAMATION U <br /> I hereby affirm that l am licensed under the provislons of Chaptar 9(commencing with Saction 7000)Of Division <br /> 3 of the ausiness and Professions Code and my license is in full farce and effect, <br /> l icerrae#; + Expiration date: <br /> r Co oar; <br /> �L, LA <br /> pato: <br /> Signature-, <br /> Title: r <br /> Printed name: "' <br /> WpRKtjRS" COMPENSATION DECLARATION <br /> I hareby.atnrrn udder penalty of perjury one of the follcWrig declarations; (CHECK ONE) <br /> as <br /> I have and will 0 of tea LaborCode,cgte f r he performaconsent to nce of the work for-Insure for which this permitTV ,is Issued.ed for <br /> by Section S7oQ CF th <br /> 100 of the 1.2bor <br /> as <br /> UjMd bSection 3, <br /> for the performance of the worm forwhich this nsadopermitr si issued. My worker$'compensation insufance�nde, <br /> carrier and policy numbers are: <br /> Carrier. Policy Numben. -- ---- <br /> I certify that In the performance of the work for which this perrnit is issued,I shall not employ any person In <br /> any manner so as to become suhiect to tete workers'compensation laws of California,and agree that if'i <br /> should become subjectto the workers'Componsation provisions of Section 37DO of the Labor Cade.I $half <br /> forthwith Comply with ft$e-Provisions- <br /> Expiration Date: Signature: <br /> Printed Name: <br /> WARNIN13:FAILURE TO 5F_CURI=WORKERS'COMPIENSATION GOVERA13F IS UNLAWFUL,ANt)$MALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIEs AND CIVIL FINES UP To ONE HUNIDRED THOUSAND DOLLARS <br /> IN AIDDITIONi TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES.ANL?13AMAGES AS <br /> PROVIDEn FOR IN SECTION 3T06 QF Tmp-LABOR CODE. <br /> AUTHOR TIO R HEFT THAN 10467 SIGNING PERMIT APPLICATION <br /> 1, {signature am-a7 ticansad authorized mpmsentative), <br /> hereby authortze(print <br /> to sign this San Joaquin County Well PenViIt Application on my behalf. I understand this authorization lis vapid for <br /> erre(1)year and 7a umit cl to the work plan dated on,the"rrt page of this application. <br /> 9-29.02{Mr <br /> EHm 29.MOT <br /> 6MM4 <br />