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07/11/00 TUE 10:33 FAX 1 911 0430 SECOR-SACRAMENTO R002 <br /> FROM : West Hazmat 0 FAX NO. 19166386613 Jul. 11 2000 07:44AM P2 <br /> 07/10/00 MON 18:58 FAX 1 918 861 0430 SECOR-SACRAAfENTO R014 <br /> 04/20/2000 00:23 2894603483 I ITTH F1.rIL1R PAGE 04 <br /> j7 � a. <br /> SatbJPPgnin GaenAEnviroAmentalHOaRR ices=UPR tY,Wet tmht p IeatictF a( , 1d0r,dwR <br /> 4 05:ADtj 0 SI SSaro4h;Fc Roa� _P�RiNt�YS�uR<f 3405 <br /> o�... ,249 D70'ooy c3'tYS Sru.W.TiD. <br /> 249'OGb-u�Z 2s7o! $Sw4fc <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby athnn mat I am licensed under the provisions of Chapter 0(commencinn with Section 7000)of Division <br /> 3 of the Business and Professions Code and my liran"is In tug foroo and effect. <br /> License#: 5 41 Exprration Date: <br /> Oath: -LIU- L7b Contractor: <br /> Sionaturar! Tide: <br /> Printed nares+ _ <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following dadaratlons: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self insure for workers'compensation,as provided for by <br /> Setlfon 3700 of the Labor Code.for the performance of the work for which this permit is isGuad, <br /> ave and will maintain workers'comperluatjon insurance.as required by Station 3700 of the Labor Code. li <br /> _Zh <br /> for the performance of the work for which tins permit(a Innued, ARV workars' Compensation insurance <br /> carrier and policy nllmbibm are: <br /> Carrier: f* Policy Number:.._P�`�/SrL✓SrLfLz <br /> _Zcertify that In the performance of the work for which this permit is ls8ued, I shag not employ any person In <br /> any manner no as to become subject to the workers'compensation laws Of Cagf0rni3, and agree that If I <br /> should hacnme subject to the workers' cnrnpenaatlan prwdsions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date:„ O /l^G U Signattlra:7i is y 99 _� ..�G✓� <br /> Printed Name; <br /> WARNING: FAILURE TO SECURE WORKEKS'COMPENSATION COVERAGE IS UNLAWFUL,ANU SHALL SUBJECT <br /> AN EMPLOYER TO CIdWNAL PCNALTIEs AND CML FINES UP TO ONE Hu NDItED THOUSAND DOLLARS <br /> (tf 00,000.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S PEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CO - <br /> r (U-57 licensed autdorised ropresentaUYe),hOmbY <br /> a oris: .A'✓1'� r-t U ast-7ir!'� .r C6.PY� .._...... <br /> to etgn thlc San Joaquin County Well Permit APPlieabon on my behalf. I understand dKa authonsation io valld far <br /> erre 1) Sar and I5 Ilrllltad m the work Plan doted on the troll pageof this aPplicadon.. <br />