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12/15/2006 09:32 9253130°92 GREGG DRILLING PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESSJ qa4. 62�L� 'PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Dusin"s and Pr .fessio s Cpc(e and my ifcense Is in full force and effect. Dn <br /> License#: 65& LtV7-- Ga Expiration Date_ 10 — -:31 <br /> Contra or. REGG DRILLING & TESTING INC. <br /> Signature: If Title, OPERATIONS MANAGER <br /> Printed name: MARX WA EN <br /> WORKERS' COMPENSATION-DECLARATION <br /> hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I havemnd will maintain a certtficats 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 /> XX I have end 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 /> Canter, __SEABR IG HT Policy Number: BB 10 6 0 2 61 <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'compensati provisions of Section 37 f the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Explration Date: 8-1 -07 Signature: <br /> Printed Name: MARY WALDEN . . <br /> WARNING:FAILURE;TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWI=UL,.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,00D.),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 N �57 SIGNING PERMIT APPLICATION <br /> 1, MARY WALDEN -b7 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> ono(1)year and is limited to the work pian dated on the-front page of this application. <br /> 8-29.02!MI <br /> MM 29-02.001 <br /> WZ104 <br />