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JUN-08-2004 11:04 FROM:PRECISION SAMPLING 510 237 4574 T0:925 299 9302 P.2/2 <br /> 06/07/04 MON 16:02 PAX 929' '309 SECOR SF it7.luu2 <br /> San Joaquin County Environmental Health Department <br /> L.init Iv Well Permit Application StIpplement <br /> permit Sit -- <br /> job Addiv-,s; r <br /> [LICTOR5 DECLARA>FION LCD <br /> I hereby af(irttl khat I an, hcensiad undor the pmvisionS of Chapter 9 (colnntcncing with Sectinn 7000) of Division <br /> the ljusines itnd Professions Code and n,y liecnse iS it) full'force mild effect. <br /> G 3 6 3 -1 _ expiration Date: 06 <br /> r, , e �,, L+L _ <br /> Contractor: S ^^S` Datr= <br /> ..fi tit:: <br /> Signature' <br /> Print N:urn: <br /> WOIt. F.RS' C[)N1I'T:NSATION DECLARATION <br /> i hetub•y arfirm under pertolty of pCrjury oiac cc the following declarations. (Check nue) <br /> t have and will inainttinl a ccrtifieste of consetlt tp s if insure Car workcrS" compensaLtoll.as prop idcd for b% <br /> Sectinn 370() of t1le 1-abor Cade, for the performance of the work for which this pcnrlit is; issued. <br /> I have and will maintain workers' compensation insurance,aS rCquired by Section 3700 ofthc Labor Code. for <br /> the portivmance of the work for which this hcrrtlit k issued" My workers' compensati011 111suranuc _arrlcr I'd <br /> policy nt.itnbers are• �� <br /> G r ,J_-fJ,I Policy Nu ibcr: �7-L33T-0.3 <br /> I certify that in the performanea orthc work for which this permit is issued <br /> L Shall not ert,ptoy rtny person 111 <br /> rely manner so as to liec;ortic subject to the workers' compensation laws of Califurnin,and agree that if <br /> should becorli.c subject h the workers' eoinpcn$atiutl provisions of Section 37OU oCt1tC L.aber Code,l sh111 <br /> forth mp with tbose}provisions. <br /> Dale: -- <br /> Signaturc: <br /> Print Name; <br /> uu cnvernKC uniarful,and 511211 Subject an employer to criminal pcnaluc' "nd <br /> Wanunga Fiillure to secure lrorkcrs' cun,yeusrli <br /> civil rfnes up to uoc hundrad chousaud dollars(S1D0,000),in uddition to the cost okornpensution,interest,,,1lurney 1"�'e <br /> and darnagCs as provided (or in seclio►t 3706 of rhe Labor Code. <br /> AUTiiOR.�'7.A'I' N FOR OTiiER TH N C-57 SiGNING PFIZMTT APPLICATION <br /> (slgnalure of C-57 IieanSed authorizu(I representat, ) <br /> I, <br /> / �� to sign this San JozAyuul foto+Cy <br /> hereby ant wrize ('print name) <br /> is�ttlid for rJnc(1) yciir and is lim,tcd to t_IL <br /> Well Permit Applicatiun on my behalf. I understand this authorization <br /> work Man dated on the frompage of this appl ication. <br /> wLU, <br /> ni?N2uU3 <br />