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Feb. 17. 2010 12: 59PM A ced GeoEnvironmental No. 6431 P. 3 <br /> <o <br /> San Joaquin County Environmental Health Department Unft IV Well Permit Application Supplement <br /> JOB ADDRESS6 tit\ t; M A,Ah , 2AUk4-M 0,t PERMIT SR#: 6-12 q <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect, <br /> License#: C57-680227 Expiration Date: 30 November 2009 <br /> Date: 16 Pebruuaary .20010 Contractor: Advanced GeoEnvironmental, Inc. <br /> Signature: Title: Vice President <br /> Printed name: Robert E. Marty <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> X 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: ,eaiey, Renton & Associates Policy Number: uH333M)22 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith Comply with those provisions. <br /> Expiration Date: 10/17/2010 Signature: <br /> J <br /> Printed Name: Robert E. Marty <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 /> ($100,000.),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 /> AUTHORIZATION FOR OTHER THA - SIGNING PERMIT APPLICATION <br /> b (signature ofC57licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaqui;Coun ell Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is Iimitthe work plan dated on the front page of this application. <br /> B-29-021 MI <br /> EH❑29-02-001 <br /> 6/22/04 <br />