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• '01/31/2002 17:33 7073745�67Z - WOODWARD DRILLING-CO PAGE 01 01/31/2002 17:59 s 7.09 b' «5 MODESTO A-,C PAGE 01 x 7ADDRESS: n County Environmental Health Services,Unit IV Well permit Application Supplement Z 14} t onfavt "'-�---- �_ PERMIT SRO: LICENSED CONTRACTORS DECLARATION (LCp} i I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 Of the Business and Profesalone Code and my license is in full force and effect. license#: . 7/0179 Expiration Date: 6 G0 3 Date: 3/- Contractor re Gli.✓G .sem C 4 Signature: Title:smr7erReYs f.io�SX Printed name; WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: {CHECK ALL THAT APPLY) .el have and will maintain a certificate of consent to self-Insure for workers'Compensation,as provided for by 4 Septin.8700 Of the Labor Code, for the performance of the work for which this permit is issued. i have and will gtaintain workers'compensation insurance, as required by Section 3700 of the Labor Cone. for the performance of the work for which this permit is issued. My workers'compensation, insurance carver and policy numbers are, I Carrier: Polley Number: DYV-O/ I certify that in the performance of the work for which this permit Is issued. I shall not employ P Y ane personIn 1 any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 i should become subject to the workers'compensation provisions or Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: — - Signature: Printed Name: WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT _ AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS i J$100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE. f ! i, �w��t✓N,E �'�fli�seraQA- (C•37 licensed authorised representadvel,hereby j e authorlae__.rft�Na/f. bfdLMSL Y f to Sign this San Joaquin County Walt Permit Application on my behalf. I understand this authorization is valid for ono(1)year and is limited to the work plan dated on the front pace of this application. s-17.2000/Ml i i i }