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05/18/2005 10:01 FAX 7073744300 Woodward Drilling 121001 <br /> 05/17/2005 13:22 9259442, TSG PAGE 02 <br /> San Joaquin County Environmental Health Department Unit N Well Permit Application supplement <br /> JOB ADDRESS:Rw /��. ni wo_ uG PERMIT SR#: <br /> l.p <br /> J J <br /> LICENSED CONTRACTORS DECLARATION (690 <br /> I hereby affirm that I em 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&C-•57 — 7/00 7 � Expiration /Date: �D 4 S <br /> Date: OE <br /> 1A 4V Air Contracto7r. WDIft kA4iC 4 D�Lt_L.//VG �ttrIC <br /> Signature: <br /> Printed name: COAAC/.0 G E tAa b ice D <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 /> I have and will maintain workers'compensation Insurance,as required by$ectlon 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: A <br /> Carrier. -V!MTS TS CA N D Policy Number: AL3 9 G 3 8 <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 provislons of Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: O Signature: <br /> Printed Name: d Q i( c,,1 C A&e..0A k)4*ge 1% <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE is UNLAWFUL,AND SHnt_u SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 3708 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTNEe THAN C-67 SIGNING PERMIT APPLICATION <br /> 1, - M.d, E (signature ofC-67 licensed authorized representative), <br /> hereby authortze(print name)_ A6 At h6/1.I./AP <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> FRI)29.02.001 <br /> 6/22rW <br />