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f <br /> +88/10/2004 99:21 2094658773 SPECTRUM EXPLORATION PAGE. 03r <br /> t <br /> , w <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> 1 5e <br /> JOB ADDRESS• PERMIT SR#:;1931111 _ <br /> LICENSED CONTRACTORS DECLARATION (IL <br /> I hereby-affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license Is In full force and effeeL <br /> LtGenst3 d: 512268 Expiration Dabs:4131/05 <br /> Date: �� '0 Cc actor. Spectrum Exploration,Inc. <br /> Sigrmtlture: Title:_0peratlons Manager <br /> i <br /> Printed name: Brenda Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby aMrm under penalty of penury are of the following declarations: {CHECK ONE) <br /> Lhaim and will maintain a certilicate of consent to selfansure for workers'Compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance o1 time work for which this permit Is issued. <br /> i „X—I have and will maintain workers'compensation insurance.as required by Section 3700 of bre Labor Code, <br /> f for the performance of the work for which this permt is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:_National Union Fire Insurance Co. Policy Number.6438303 <br /> l I certify that in the performance of the work for which this permit Is issued,I shall not employ any person in <br /> any manner so as to become subject to the worltero'compensation laws of California,and agree that If 1 <br /> should became subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> I todhwith comply <br /> /Jwith those provisions. <br /> Dew: Signature• <br /> Printed Name: Brenda Crawford <br /> WARNING-FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (=100.000.1 IN ADDITION TO THE COAT OF COMPENSATION.INTEREST.ATTORNErS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3TOS OF THE LIBOR CODE. <br /> HOR ON FOR O THAN C-67 SIGNING PERMIT APPLICATION <br /> 1,, Bre rd,of Spectrum EYptvratlnn,Inc.,_,(signature dC,ST licensed suthoriced napr$ssnletive), �1 <br /> hereby aulhoAm(print name) Ui�� <br /> to sign bile San Joaggln Courcy Well Permit AppOridren an my behalf. I understand this authodmilon Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application, <br /> B-2"21 MI <br /> RECEIVED TIME AUG, 10. 9: 12AM <br />