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08/02/2005 09:12 9253130302 GREGG DRILLING PAGE 02 <br /> San Joaquin County Environmental Meaith Department U171t IV Well Permit Application Supplement <br /> J08 ADDRESS: 1022 FRONTAGE RD, PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONLi Cay <br /> l hereby affirm that I am licensed unddr the pravlslens of Chapter 8(commencing Wth Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License#; 4 8 516 5 l=xpiralon Date: l'-31-06- <br /> Date:- <br /> 31-06- <br /> Date: 08-02-•05 n r: GRE GG DRILLIMT & TESTING, INC: <br /> Signature: Title: OPERATIONS. MANAGER <br /> Printed nahne: CHRISTOPHER PRUNER <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty Of pedury'ohe of the following dedaratiohs;".(CHECK ONE) <br /> 1 have and will maintain a certificate of consent to aoif.Insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of tha work fer which this permlt is issued. <br /> —2L J have and Wil maintain workers'compensation insurance,as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this permit is•!ssued. My workers'compansatiorl insurance <br /> carrier and policy numbers are: . <br /> Carrier. SEABRIGHT policy Number: $$1050261 <br /> I certify that in the performance of the work forwhicy this permit is Issued, 1.shall not employ'any person in <br /> arty manner so as to become stltlect to the warkers'compensation taws of Callkrr ia, and agree that If'i <br /> should t;acome subject to the workers'.cornpensation rrovtsioris of Section 3700 of the Labor Code, I shall <br /> `orthMth comply with those provisiona. <br /> expiration Bate; .8-1—0 6 Signature: <br /> Printed Narne. CHRISTOPHER PRUNER <br /> WARNING.FAILURE To SECURE WORKERS,COMPENSATION COVERAGE IS UNLAWFUt,AND SHAL.-SUkJECT <br /> AN EMPLOYER TO CR1NIMAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,400.),1N ACCITION To THE COSTOF COMPENSA71oN,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PRGVIOW FOR IN SECTION 3708 OF THE'LABOR CODE. <br /> AUTHO ION QTNEJ4 THAN C-67 SIGNING PERMIT APPLICATION <br /> l+ (afgnat:im efC-5711consed authorized representative), <br /> hereby authorize(prim narne) CAMBgl ENVIRONMENTAL TECH <br /> + <br /> to sign this San Joaquin County Well Permit AppOcatlon on:ny behalf. I understand this auvorization is Yalid for <br /> one(1)year and Is limited to tho work plan dated on the frontpago of this Application. <br /> L"-42 MI <br /> Fpm 2P-az-ooI ' <br /> 6r2y0o <br />