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03/05/2008 11:57 9253130%0,t GREGG DRILLING v/ PAGE 02 DAD <br /> Mar. 5. 2008 1"i :34AM Advancad GecEnvironmental No- 1339 P. 2 <br /> San Joaquin Gourlgr Environmental HeaRA Dspartmant Unit IV Well perndtApplication Supplement <br /> +�{04 i*t Fk(A �rrY PERMIT SR#: <br /> JOB ADDRESS: y0 f nnr TR ORp awe 0, <br /> LICENSED CONTRACTORS DECLARATION LCD <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 licenee is in full force and effect. <br /> g �5 6miraton Date: { j 31 1 ad2 b <br /> Llcenae lt <br /> Date: <br /> YContra .,, Y7 <br /> Signature: Title: <br /> Printed name: S <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty Of perjury one of the following declarations: (CHECK ONE) <br /> of consent to <br /> for w0rhers' <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. d for <br /> X I have and will maintain wO"re'c0mpens20on Insurance,as required by section 3700 of the Labor code, <br /> for the performance of the work for which this perm@ is issued. My workers'compansation irSUran0a <br /> canter and policy numbers <br /> nnum�bers are: <br /> �n `� (n <br /> Carrier: S_\ L`Si I 1 V Policy Number. 12 a O "' <br /> 1 certify that in the performance of the worie for which thin permit is issued,I shelf not employ any person in <br /> any manner so ore to become subject to the workers'compensation laws of California,and agree that it parson <br /> should become subject to the workers'compensation p"cdFS"e0on37of the Labor Code,1 shall <br /> forthwith comply with those provisions. <br /> Expiration Data: Signature: (� <br /> PrintedName:t�rl <br /> WARMING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANO$MALL SUBJECT <br /> AN EMPLOYER TO OMMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($Joa,000�IN ADDITION To THE COST Of PROVIDED FOR y7 SECTION 3706 OF THE LABOR COOT.COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> =OFR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> signature ofC47 Ecensed authorized representative), <br /> hereby a amore(print norma 1 <br /> to sign this San Joafuln County VFell Permit Application on my behalf. 1 understand ons aathorlzat[on is vend for <br /> one III year and is limited to the,wonr plan dated on lime front page of thls application. <br /> 549-02/Mi <br /> Eim 29-02-001 <br /> 6/22104 <br />