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Feb 10 04 02: 37p WESTFX (916) 373-0548 p. 2 <br /> 02/10/04 15:08 FAX 916 920 8� .CH2.M HILL SAC 10002 <br /> 63/2612903 16:25 2094683433 <br /> FIFTH ELD[7R PAGE 63 <br /> FJOB <br /> n Joaquilrl County Envlronmental'Fiealtl:UeABrtmertt unit IV Welk ftn tit APPRatiDn Supplement <br /> ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 hei eby—,gfirm that I atn licensed cinder the provisions of ChGpter 9(C=rnencingvAth Ssetion 7000)of Division <br /> 3 of the Business and PFofesaions Code 2nd,my license'sin full fw:;P-and 6� 0 5 <br /> C57 ,#552198 <br /> License k- _ pcpiration Date-. <br /> 02/10/04WESTERN STRATA EXPLORATION, IN <br /> Date: C trdctor< <br /> Title'. PRESIDENT <br /> .Signature: <br /> Printed name: SYLVIE C. JE EN <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby atfkm tlnder.penalty of perjury one cif the following ded'ara(ione (CHECK oNr=) <br /> I hair©and wi11 MaMtain a cajttcate oi'consent to self-Insure for wprkws'cQMPensstion,as,provided for <br /> by Section 3700 of the Labof Code,for the performance of the work for rwhlc?t this permit is issued <br /> I have and*111 maintain Workare compensation insurance,as required by Section 3700 ofthe LatrorGbde, <br /> for th&performance of the work for which this permit is issued: My workers' contpensalioYi insurance <br /> carr(erand poliay'numbem are: <br /> STATE COMPENSATION FliND pullcy Number. <br /> Carrier. <br /> 1 certify.theln the performance of the workforwhirli this permit is issued,l sh811 not employ any parson in <br /> any,Wanner so as to l7ecoma sut3iect to the workers'compensation Caws of Califnmia,and agree that)f I <br /> should bticome subject to the workers'Cornpensatiori provisions of Section 3700 of the Labor Godo,l.sha11 <br /> forth"Comply with tlipse provisions. <br /> Date: 02/10/04 <br /> SYLVIE JENSEN <br /> p(inted f0me;:' <br /> WARNING-FAUj*E TO SZCURE WOW.9RS'MUPENSATIDN COVERAGE 1S UNLAWFUL,AND SHALL SUBjEOT <br /> AN EtVIPLOYEkTo CR41v♦tlNAL p�1ALTIEG'AND CIVIL FINES UP TO ONE HUNDRED THOUSAND bOLLAPS <br /> (5100,000.],iN ADDITION To THrz C05T OF COMPENSATION,INTEREST,Ai 7ORNEY'S.1°ESS,AND DAMAGES AS <br /> pROVIDFO FOR JN-SEanoN 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAM C-57 SIGNING PERMIT APPLICATION <br /> SYLVIE C. JENSEN (zigrature cf6-57 licensed authorized mpresent3tcN4. <br /> 1, <br /> hersbyauthooze(print name) CH2M Hill <br /> to sign alts San Joaquin County Well Permit Application on my behalf. I understend thisau'thorizatlon is valid for <br /> one(1)yearir and is Ilr'nited to the work pian dated on the front pas4 of this application. <br /> 8-23-82 1 MI <br />