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Jun 18 02 07: 00a WE&X - (910373-0548 P. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application-Supplement <br /> JOB ADDRESS: 75 West valpi co Road, 'Tracy, CA PERMIT SR#: tJ��OI d <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: C57 #552198 Expiration Date: 06-30-02 <br /> Date: June 17, 2 , c5rtrator: Weste Strata Exploration, Inc <br /> Signature: Title:General Manager <br /> Gordon <br /> Printed name: JY,Jensen, Jr <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (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 /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> XX 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. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: State Fund Companaation 7ngi,r.Policy Number:-j-5697g1i,02 <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, a,", <br /> agree that if I <br /> should become subject to the workers'compensation provisions of Section,-3700 of t Labor Code, I shall <br /> forthwith comply with those provisions. <br /> 2002 <br /> Date: June 17, Signature: <br /> Printed Name: Gord n <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COY AGE 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,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, Gordon D_ Jensen T, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name)_ Acton-Mirkelann EuvironmAntar <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 1-25-02 I MI <br />