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12-14-204 7:57AM FROfP. 1 <br /> ..v <br /> PPtlM StNphan!.c 9e:rrengtan FAX M8. 9166811168 . . Dec. 14 2004 07:40AM P2 <br /> 12i 05/20da15:11 a6a013S ENJIRONMENTCd. HEuL.TH PAGr 02 <br /> __. <br /> - lament' <br /> San Joaquin CountyRavoanmanta!tiea1t11 t7epathnerf!Uql!W"I RPAIIIlAOINiCaNOn SUPQ <br /> dO8 <br /> —L90)--,4 <br /> S• <br /> w F• p>nPIT �Rlk <br /> L ICEpl3ER CQNl Rs UECLAPA-IDN., wtj) <br /> 1 hWadY afl5rm that t am ripensad urderMw v�1O��Cltapler 4(CammBnCMft7 <br /> oath fieaPan 79M.of DOL-k <br /> 3 of wg'so"Mms and Pcoless"Codo MOW=hid form Oro eTkCt <br /> ) I . <br /> Wcersse tk. � 3 �5 miratian URN:�l--+.' <br /> A ftyl7t�nfY�e� C <br /> stg�atu,e: <br /> Pnmedname: 1 1�Qd�c1 SC•�r "'�` <br /> WORKWta,COMPENSATM M*_ARAJON <br /> t nareby a"rmaer Pin"Y of peruy,due otthe tdtoMn9.<kr�r+yprie�'(CHECK MM .. <br /> a$pmyidcd for <br /> i have and'`vdl mamm Usstt <br /> a cgf5$=g*at c*ment%self re for walcets'oompetw� . <br /> -"py ppn.3700.of the Eahoi Code.for the Fad 0(4ta W41kfp•vdlldr oils pw.mk W.lasugd. <br /> insarastce,as tequ reo>n Sewn"VW of g e.Labor code. <br /> ✓ittSve afldWill tiMltltPlR�ara'mmpensa6an. tiV,yp��:.pp7np71?644aA:RYaUr>s!� <br /> . '""}atfhC pfatNeofthe watictorvedch Oals:t `s' •. .. .: . �ry� <br /> y� Y is issued.!shall txA emgeY anY person Ir+ <br /> 1tecUfYtnstinthaP�f�a?aftheWo�to�whtcti, ' 'P�n �{.agree.th?ld.t <br /> any'monn9rsa�bDfo� •C �n.tewsefCefi,EorttiA: <br /> to therbflwr4 C��Iswna at gp�{iora TlCO.of fie Cabor CDpO.(9t19G <br /> ... foA6nvdh:aomPN�vvrnf tltoca Prevrma+s•. <br /> r=ycpeatlOt�.tJale:, .Z1'O 5ty(relnrac <br /> prfeledNaenr .. . <br /> yynin G.P#JLURF,,�ti5C-CoIREf 7tlER5`CCf .IFK4R'llOtiCOVERIAGEIauNL� �L. SES <br /> y ,e,'E� TO C'nanwa-rehnLS n7tncnd tar. �;• s rE6,s.�f{o e�a es'As <br /> AId VpCOST <br /> tSft�tleQa61NACCfCiONTot1EOF m ' <br /> PR PgtRrils N <br /> AUTHaR1�A=M FOR gZMT"AM <br /> C:Sf sIGNUNO PERNAt'APPLMATION <br /> hereby,"itmua 14r3�mom ~ . <br /> ��p�{t�fiCeOaa +47f ''IuadersUMtt7+baWkerka50n fa P7ltd tat <br /> f .aptwo can J"Ram OnUmly <br /> o7NbaAbNeatlgrt <br /> rand Is VMIwn w.a*VM* dead anslW*ro*t'p'a" <br /> ern f1}yea .. " <br /> . . . 899.021 he <br /> 6RL� <br />