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03/13/2007 15:15 5102;74`74 PRECISION SAMPLING PACE 02;192 <br /> 03i73i79G]7 11: 11 5E0r-0IX-RRNCHn COP.DOVA i 15102374574 . N0.529 902 <br /> �, i� Qcra¢ai[tL, �SJd� 237 , VS7� <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS; 2 9'02 G�tS��"`' PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION QnC__,)D <br /> I hereby sArm that I am licensed under the provisions or chapter a(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 k: 45, 3 6 3 8 Expiration Date: 1131. 108 <br /> Date: 3 0 contractor: <br /> Signature:��_„ �-G=—�J Tltto: <br /> Printed name: 1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following deciarations (CHECK ONE) <br /> ,have and will maintain a certifcafe,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 /> y. 1 nave and will maintain workers'compensation insurance,as required by Section 3700 of trio Labor Code, <br /> T'for the performance of the work for which this permit,s issued My workers'compensation insurance <br /> carrier and policly numbers are: <br /> Pi Policy Number, " Ci ' <br /> Carrier <br /> I Certify that in the performance of the work for which Inis permit Is Issued, I shall not employ any person in <br /> any manner so as to become subject to the workerscompensation laws of California,and agree that if <br /> should become subject to the workers'compensation provisions of Section 5700 of the Labor Code, l small <br /> forthwth comply with those provisions. <br /> EJgtlration Data: Signature: / <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IFOR ISECTION <br /> IN ADDTTIONTO <br /> THE OF THE LABOR COMPENSATION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVIDED <br /> AUTHOR17AATTIION FORQTN,zR T�Hr-AN C-57 SIGNING PERMIT APPLICATION <br /> q-j L�r'N*atuee WC57lie8naed authorized representative), <br /> , <br /> hemby authorize(print namet G r.¢ y Ni12 h Vti G <br /> to sign this San Joaquin County Well Permit Application do my behalf. I understand this autholtutiion is valid for <br /> no(t)yoarand Is nmltod to the work plan dated on the front page of this eoplleation. <br /> a4e-02 1 MI — <br /> rr:o 2o.m.00l <br /> 4=04 <br />