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12/15/2006 09:32 925313P"12 GREGG DRILLING' PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESSJ Cao. 6a�: �P.� ��PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION L{ 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 Businpps and Pr fessloLt7's Code and my license is in full force and effect. <br /> -FS (� <br /> ' S i�� " <br /> License#: 656 'f07— Expiration Date- 10 - :3] _69-- <br /> ---Contractor <br /> Og- <br /> -Contra or. REGG DRILLING & TESTING INC. <br /> Signature: -"- <br /> Title; OPERATIONS MANAGER <br /> Printed name: MARY WA EN <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I havemnd 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 /> XX <br /> 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. Myworkers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. SEABR IGHT Policy Number: BB 1 060261 <br /> I Certify that jn the performance of the work for which this,permit is issued, I shall not employ any person In <br /> any manner so as to bedome subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensaH provisions of Section 37 f the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 8-1 -07 Signature; <br /> Printed Name; MARY WALDE14 <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,ATTORN_ErS FEES,AND DAMAGES AS <br /> PROVgDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER N -57 SIGNING PERMIT APPLICATION <br /> I, MARY WALDEN -67 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permlt Application on my behalf. I understand this authorization Is valid for <br /> ono(1)year and Is limited to the work plan dated on the.front page of this applleatlon. <br /> 8-28.021 M1 <br /> Mm 29-02-MI <br /> 6r1.?1t1t • <br />