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12/3112007 10:53 92531303 GREGG DRILLING PAGE 01 pfd <br /> Dec, 2$. 2007 10:55W Advarcced Geo�nvironrnental No, 0672 P. <br /> FSSanoaquin Coun'kyEnvironmental Health Department Unit IV Weil Permit Appllcrltton SupplemenDDRESS: , ,.. ..__,. Eomaw <br /> ss S �A - PERMIT SR#: 00331 <br /> LICENSED CONTRACTORS DECLARATION Lt GD) <br /> I hereby affirm that I am licensed under the provisions of Ghapter 9(commenc'ing with Sectlon 7000)Of Division <br /> 3 of the Business and Pro <br /> cL ees�sJJslo//ns Code and my license js in full force and effect. <br /> Llcense E !ration Bate: <br /> 1 + <br /> Gate: C gntra <br /> Signature: Title' <br /> Printed name: <br /> WORKER 'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of tho fallowing declarations; (CHECK ONE) <br /> I ha►a and will malntaln a certificate of consent to self-Insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code, fvr the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section$700 of the Leber Code, <br /> forme performance of the work for which this permit is issued. nay workers' compensation insurance <br /> carrier and policy numbers are,- <br /> Carrier <br /> re_Carrier• Policy Number:. f &f .-- <br /> I certify that in the performance of the work for which this permit is Issued, I shall not Employ any person in <br /> any manner so as to become subject to the workers' compensation laws of Calitarnia,and agree that if I <br /> should become subject to the workers'compensation provisions of section 3700 of the Labor Code, I shall <br /> forthwith comply mO those provisions. <br /> Expiratlon Data: � Si r;ature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION CO ERAGE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000,),IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTQRNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION Sine of THE LABOR CODE. <br /> UTHORIZATI FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> lF (signature ofC-47 lieanaed authorized representative), <br /> V IV/1 <br /> hereby outho (print name) QA ' <br /> to sign tliia San Joaquin County Wets Permit Applicationa my behalf. I understand thi$authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front gage of thls apglicatien. <br /> 9-29-021 MI <br /> EHD z9-07 401 <br /> [I4 ^A <br />