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NOU-21-2001 15:10 _ GEOMATRIX FRESNO - 559 264 7431 P.05i12 <br /> i <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> : JOB ADDRESS: � Yh PERMIT S,,: <br /> Corel *O an4line. 9d., 7Mc3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Seton 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License : C 57 0 512268 Expiration Date:_ 04/30/2003 <br /> Date: fl-) -Q1 Contractor: Spectrum Exploration, Inc. <br /> Signature: Title: Operations Manager _ <br /> Printed name: Brenda rawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I haire and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My Workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. American Motorist Policy Number: 3BG03575800 <br /> _I certify that in the performance of the work for which this perrrM is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers'oomperuation laws of California.and agree that if I <br /> should become subject to the workers'compensation prov Ions of Section 3700 of the Labor Code, I shall <br /> forthwith damply with those pmviWons. <br /> Mae- Signature. <br /> Printed Name: Brenda C wford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> %1100.000.�IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, Brenda Crawford of Spectrum Explor.(signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) x S <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one 11)year and Is Iimlted to the work plan dated on the front page of this application. <br /> 5.17,20001 MI <br />