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06/05/2008 08:30 2893699608 U&W DRILLING PAGE 01 <br /> .4d3q:3 <br /> [ San Joaquin Copgty I;nYronrnental Meatth Department Unit IV Well Permit Application supplemen#el <br /> JOB ADWORESS: PERMT SR# <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> l'hereby affirm that I am licensed under the}rasion of Chapter 9 (oommerlcing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and e <br /> rra <br /> License#: .C)C1 ® Date: L4 <br /> 3o loo I t <br /> Data: D Contractor: <br /> Titre: Wy, <br /> Sigl�ature: � , <br /> Print No": <br /> W:ORKEft'S CQMPENgq N DECLARATION <br /> I hereby affirm under penalty Of PMW Otte of the following declarations: (aleck one) <br /> IIE <br /> I have.-Intl-will.-mairdain a-cel ficatG Of consent to self4nsure fnr workers'con"na9tlon, as <br /> provided br by- 3700 of ft labor Code, for d*performance of the work for which this <br /> permit is issued _ <br /> !have and will.mvintain'workers'compensation insurance, as required <br /> by Section Labor Code,-for the performance of the worts for which this permit its issuedMy workers,f the <br /> compen n 1n3'urj ecarrl and policy numbers are: <br /> Carrier: f� <br /> Policy Number: 13-:-- <br /> V0 — D <br /> I. <br /> certify iiia#W1 the e_ <br /> person m any mane of the work for which this pelt Is issued, (.shaft not employ any <br /> WW <br /> so as:to.become subject to the workers'compensation law of California,and <br /> eSn e.that if I Should beoprrd•subjed to workers'.compensation provisions of Section 3740 of the <br /> Labor . I s 11 Ply with those <br /> pro ns. <br /> Exp. Daft: Sionatur'e: <br /> Priet Name: l� <br /> 1Ab{RIIrMG:CRWAL A P SECUkALT E Wig.DOWEWMTIOW COVERAGE 1$UNLAWFUL,AND S ALL S=gCT AAI EMpI. <br /> CRAYANgL PEkAL7iES An L:1W r F11 UP TO i I Og600.[�1 AODI770N'TO THE COST �ENSA7iON,(r ig TO <br /> ATTORHEy�g FEE,9. D.DAt11AC31;$I SpRDVIDEp FOR IN SEC77ft 3706 OF THE LABOR MIRE. <br /> !; <br /> R OT" <br /> THAN C 57 SIG !NG PERMIT APPLICATION <br /> h&9by authorMe(print name) ( nature of, T#ic represents#ire), <br /> �P this San Joaquin.moyrrty 1Kail Petnflt !l � ,to <br /> App catlor�on rrry beh If. I uhtld this alttltorQatton Is raltd <br /> for one year and is Limned to the Work.plan dater!an the traont page of this application,icatlon. <br /> ��-07 f1iSA11' <br /> VVEU PERW AM <br />