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f O 1 : 29AM HP LASERJET 3200 P. 1 w �r zur�l 1;10 2094E 33 FIP7H FLOOR PAGE @a i San aJ in Colt&F�ri&onmenta�H It Sgrvices Bn� / IV�I�Perm t licat on So Ilment an oaquln o n y nvironmen ales ervrces', n e arm rt l�pp Q�atian uppie n J O BJ'�9�• 3l>�?S� 2 i DECW&MOMLSD) I he eJtfyetyiaffi►r�tthandd&fhd �tlplRf+ �Sc11� @4�(�9?filfilri' Rt�@ �'6 �3fv ion 3 of se#: �7 �s �E i tion a e: Lice x 1r'a ion Ba e: Dat Date: Z ontr tor: 1 / Signature: Title: i ature: 116 Printed name: Printed name: WORKS S' C WORKERS' COMPENSATII�Dt,CLl� �� I hereby offirm under penalty of perjury one of the following ec rations: ll L THAT APPLY) he eby tvtYofacc� � at �c � f�i9haeawlmnaine " WOAVOWa� _I havi a wi TOOofa nLa certiticaete of cor�sent to self-insure fokWorkeir�s'tcompenisat t is onu as provided f by c a�� 8�i�er�a n r rc } Fl3l fl�gr i�� rfit�d )git a�TObxkf ts58tr }.Codo, for the performance of the work for which this permit is issued. My workers'compensation insurance _ havtOIJ4}gi�hpen sation insurance, as required by Section 3700 of the Labor C de, or the performaXe of the work for which thisp ermit is issued. My co i n Insurance Carr pQI `r dS arm Policy Number: C rl;certify that in the performance of the work for �thJ et Is Issued, I shall not employ any person In any mann t e�rZbrrr Q,�i��h Ots af Galifernia, and agree!hat if I q I b u ct to the gr�kers'c?ven$ tion provisions of Section 3700 of the Labor Code, I shall cert �rth i��r +lf�PoA?r r w t h;his permit is issued, I s all not employ any perso in n manner a become subject to the worke co ensatio la s of liforni and agree that if d bec I fttae-the wo ftft�tci en ion I s all orthwi Co p y with those provisions. ��K1 ��Z ,_, / Printed Name: V Dat Signature: WARNING:FAILURE TO SECURE WORKERS'-CUM P ENSA I ION COVE RACE 13 UNLAWFUL,AND SHALL SU—BE0 T N 2SRFLl7 cR TO C41"4!FlA rp �16r41.� �s AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (p$R1000,,000.)p),IN ADDITION TO TNt;�oS "C -- p��;:'^c rVE-S. WA NTNG:I A"'REITSECTION SECURE WORKERS' OMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJ CT AN MPLO O 1 ALP fig.CLINIC FINES UP TO ONE HUNDRED THOUSANDDOLLA S OE N A O S PRO IDE FOR IN SEC ION 3706 OF L�� rCO D authorize(print name) 1 to sign this San Joaquin County Well Permit Application on my If (understand this authorization is valid for Mlicensed authorized representative), hereby auth one (t)year and is limited to the work plan dated on the front page of this application. 5-17-20001 Ml to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one(1)year and is limited to the work plan dated on the front page of this application. 5-17-20001 MI