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Sent By: Gregg Drilling a Testing-, Inc. ; 925 313 0302; "&1-5.01 i,3:23; Page 313 <br /> 10105/2081 11:AS 209-514125 MMST0 ATC PAGE 93 <br /> to :, <br /> Satz Jesquin County ttivironmerltsl Health Servkes,unit 1K Will Permit Appikstion Suppl <br /> JOB AWRESSIXA PERMIT SRO: '••- <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby a9wrn that I am Naensed under the provislons of Chapter 9(commencing with Section 7000)of Dmia <br /> 3 of the oust*"aniPlaftsma Code and my license is M hilt ford and effscL <br /> L.iw ws 0; GS7 �. ,,�_Expiration DOW <br /> Date;D!acContractor <br /> Signature: TiNe: <br /> Printed name.S.z<u <br /> WORKERS'COMPENSATION DECLARATION <br /> I harr;by t1Mrm under penalty of po4wy ono of the following dedantions: (CHECK ALL THAT APPLY) <br /> 4'hays and will Maintain a Cooftgele of 00(19W to se"sure for workers'oomper'""M as provided for by <br /> Ssiftn 3700 of the Labor Code,for the peAorrnance of the work for whloh this permit Is issued <br /> - <br /> Itivs srtd wtli maintain Workters#comi"atkxt insurance,as required by Section 3700 of the Libor Cock, <br /> for the performance of the work for Wh"this Permit is issued. My workers'oompenmftn insurance <br /> carrier and policy nttmbsrs an: . <br /> CsreierOC �'� PrPolky Number. <br /> I certify that In the porfotmarrce of the work for which this Permit is issued,i"not employ any person in <br /> any manner m <br /> so a to booms sub)eci to tin wwrkars•oorrtpensetlon kws of C 1ornis.and age that 91 <br /> SMl lid bacOr tojbWto the wrort%@W colnpertsatlon provisions of Section 9700 of the labor Code,i shall <br /> kMwhh comply with than provkbns. <br /> Data: /4lS l0 _ 8ignatwe: 7 <br /> Printed Hen": %�. `� �•'=' � <br /> wA1oM4 <br /> .FAIL M TO SWURE WORKEW COMk"SATtON COVERA X ss UNLAWp{N..AND 5W%.0 suBACT <br /> AN EMPLOYER TO CRIMINAL J00ALYI ES AND CIVIL FtN95 Up TO ONE"~to THOUSAND DOLLARS <br /> (SItaPO.�W A001!11"TO THE COST OP COMPEN"MM,INTEREST,ATTORNEY'S FEES,AND DAMAO93 AS <br /> PROVUM FOR IN,SeCMN 3M OF THE LAWK CON, <br /> u��/i. _tC-til Iloangd auttaAssd repreeintativs�.hsn�by <br /> suttroriss <br /> to sign this San joaquin County Well Permit Apptieedw on sly behalf. t undsrstsnd this suthorisstlon Is vsltd for <br /> ows(t))Isar and is Hn"d b the work Mian dated on the front peps of this appiks kl* <br /> S.'Q- f iAi <br /> Y <br />