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06,113/2006 17:y17 707374566 WOODWARD DRILLING, CO PAGE 01/01 DU2IUDY JOS ADDRESS:-u.._........... „ ...... P ERMIT 5 q n Environ-'.-Hn4 .w._. _,,.�..Well P.............p_.. I Countyal Health Oe artment Unit IV Well P9m7(t A plieetion Supplement 9®�! /� A R#: fat/ 0,2/i3a // LICENSED CONTRACTORS DECLARATION i 1 hereby affirm that I am licensed under mho provisions of Chapter 9(commencing with Section 7000) of Division i3 of tyle Business 511d Professions Code end my license Is in full force and effect. License k -7/0022 Expiration Date;_ � �? Date: O 4, Contractor: &J00.04.0/9-oe L Lv 6 C f) �i nry Slgnatur Lam. Title: -�1.�-o-c�-e��P` Printed name: I WORKERS'COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations' (CHECK ONE) i _ I have and will maintain a certificate 0t,Consent to self-Ensure for workers'compensation, as provided for i i ty Section 3700 of(ho Labor Code, for the performance of the work for which this permit is Issued, I have and will maintain workers'compensation Insurance,as required by Section 3(00 of the Labor Code, ' for the pelformanoo of the work lot which this permit,is issued. My workers'compensation Insurance carer and policy numbers are: �y Carrier., Policy Number, O 4-4/ Oaf b -7 I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so AS to become subject to the workers'eampensation laws of California, and agree that if I should become subject to the werkers'compensation provisions of Section 3700 of the Labor Code, I shall i forthwith comply with those provisions. Expiration Date; /O D t- Signature: 3;7- -- o _ X � Printed Name:�E7NGi^3 jo;- OO64,, I WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHAW.SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN APPITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As PROVIDED FORM SECTION 3706 OF THE LABOR CODE. I i AUTHORIZATION FOR OTNER THAN C-57 SIGNING PERMIT APPLICATION ofC-6711ccnsttd authorized rflprosonfative), c hereby authorize(print nemo)_.-Ar , i to sign this San Joaquin County Well Permit Application on my behalf. 1 undaeotlnd this authorization is valid for i enC(1)year and is nmlted to the work plan dated on the front page of this'application, 5.29.02/.M1-, I,III1;,n^mn