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JIL-05-00 WED "09 :23 PM ENPROB <br /> ATC PLEA5ANTON PAGE 02 <br /> _+ 07/04/2000 21:49 925-4 ',;� 02 <br /> 0b/30j�Q80 _14_52 925-737--5319 ATCEM PAGE <br /> San Jttet}utfl 09%Mty INFAVIroamentaI Real Smvicw.Unit lY Well Permit APPllcatlola,`CupPtomerd <br /> .ra�,Ac ss- yi�mnr rC�� PERnlur si2lf: <br /> L.ICrSKSED CONTRACTORS DECLARATION {LS'el2i; <br /> I IsoesbY aflttm that r�n Itcenaed under the provle(ons of Chapter G(WMft! 0iftg vd1<i Section 7000)Of pMiaion <br /> 8 of the Suslne"and praftssW3 Cade and my ISG2rWe is in toll force and <br /> GM <br /> DaJ7 Ejrpira[ieit Date <br /> .7 k <br /> `Dew <br /> Titles� s a.��c�✓' <br /> sisnatun: <br /> printed names <br /> WC7FiKELiS'COMPENSATION OKLARATION 1 <br /> I hereby affirm under penalty of perjury one of <br /> foflOWing tlgclar8tiens: (CHECK ALL THAT APPLY) <br /> I have and wd1 rnalAtain a cerurrate of eonsem to segansure for worksrs compensation.as provided for by a <br /> $eMion 3700 of the Leber Code.htr the parfonttfnce of the work for which this permit Is I.-AWe. �. <br /> I have ani w11 matntaln workats`camp0nsatnon insunarnos.as required by section 3700of on near w code, <br /> for the performance of the work for wnich thle permit is issuetl. My warimra'campe <br /> carrier and vdicy numbers are: <br /> pansy Number- <br /> I certity that in the perlbrrnence of the work for which this Psrma Is Issuwd:I shag tut employ SAY person in <br /> any mann er so as to become eubleet to lh a Workers'C"ll"Batlon laws*1fal'dornie,end agtrse that if 1 l <br /> should beco"le subject to the workeeaenpensatiOn pr WWOns of Sea" of Site I atsar Code,I span <br /> rs' <br /> fnrtYiwithcb N with the"proviet8"6. � <br /> Gate- 7 .S t3ignaLgAz f <br /> Printed Namei ` <br /> WARNING 1 FA10N ILURF TO SEGM WORKENS'CONPCN$A7COVLMGE 1S UNLl+ninipllt,AND SHALL SUBJECT <br /> AN"ApLOYBR To CRIMINAL LTI <br /> PEIIAE�AND CIVIL FIMUP TO ONE HUMORM TMOU3/lND OOUARB <br /> ($108,000.1,IN A0DfWN To TRE COAT OF GompaNSAT10N,eWT&REST,ATTOR"y%PLEB,AND DAMAGES AS <br /> PROVIDED FORM 813=0N SIN OF TWU LABOR C00E. <br /> t (0-Uf to w-ad aa0iare»d raerasenfative),huchy <br /> ond7to <br /> to sig"this San Joaquin C9wdy WOU Pe+mll APPUOuron un my behmm I undoremnd Ulla#uMOl'tiarion 19 valid for <br /> net oar and is Ii tied to d'ne vAerli Wn dated oe rhe t a of th fi <br /> f� <br /> E <br />