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Mar. 13. 2007 8: 37AM Advanced GeoEnvironrrental No- 7909 P. 2 <br /> fson Jogquin County Envirronmental Hea;kth Departrinant UnR IV well Permit Application Supplament <br /> ,109 ADDRESS: ����° N+ 1.���� �7 PPRMIT 5F�: <br /> LICENSED CONTRACTORS DECLARATION (L <br /> I hereby affirm that I am liwu6W under the provisions of Chapter 9(tximmencing with Sootion 7000)of pivision <br /> 3 of the SUAlness and Professions Cade and} my libense is In full force and effect <br /> Lloenae V: - -71 J rcpiration Date: ` <br /> ' Date: U Oo Cont r, �� S G C�O>' ri ` I V�� <br /> 9lgnatum; Titie; SaxJ <br /> Printed name <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby aMrm under penalty of perjury one at the following declarations: (CHECK ONE) <br /> 1 have and will maintain a certiftate of consent to self4naure for workers'nompensatlon,as provided far <br /> by Section 3700 of tha Labor Code,for the performance of the work for which this permit is Issued. <br /> _I have and wll maintain woNers'oampensatlon Insurance, as required by Section VU0 of the Labor Code, <br /> for the perlorrnance of the work for which this pormit is issued. My workers'compensation insurance <br /> carrier and policy numbers ere: <br /> ll Ili aio�a�( /- "' 05 <br /> Carrier: i�4 a S� N -- Policy Number. �i w <br /> I certify that in the perft7rmancae of the work for which this permit is issued,I shall not employ any person in <br /> any nnanner 96 2s to become subject to the workiers'compwimflen laws of Callfomia,and agree that if I <br /> should become subject to ma workers'compensation proviabns of sewn a7 of the Labor Code, I shall <br /> forthwith compty with those provisions, <br /> 7 <br /> Expiration Date: J ,Signature: <br /> Printed Name: CJS G <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND RMALL 81.1840T <br /> AN EMPLOYfiR TQ CRIMINAL PENALTIES AND CML FINSO UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPINSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN BECrt0143708 OF THE LABOR CODE. <br /> AUTHORIZATION OTH THAN C-57 3IGNING PERMIT APPLICATION <br /> I, (algnaturs aM-57 licensed authorized raprmmrrtativo), <br /> humby authorize(print name) i' I L GUvZ <br /> to sign this San Joaquin County Well Permit Applicatloh on my behalf. I understand this authorization is valid for <br /> one(4)year and is limited to the wvrk plan dntt&d on tho front page of this sppi(cat)oeti <br /> 8.29-p2/lNl <br /> EHA 2442-003 <br /> 05Ina <br />