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t <br />P-2 <br />•' 3-24 1997 3'= 08AM FI <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS:S HFNV1R0NM6NTsAL <br />399 SHERVS PLACE <br />LI C E N S E a/QbbftX kigfiE�e'QA?5Mb 0,M) <br />PHONE# (209)772-3570. FAX # (209) <br />1 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 #: <br />Expiration Date: <br />San Joaquin CWnn <br />Date: tra r:Envlronmen aeatDeyafti <br />Signature Title; <br />Printed naStpck�Orl, CA 95201 <br />WORKERS' COMPENSATION DECLARATION <br />RE: Well Permits <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have �rd(�ii etaby3 �t�>{ic �oQ If WXr�Ah rrT9h'satt�lO ierovided for by <br />Section myQ„o�ffi�g�&d fbftkfft r elpfeFmRs)r icAdd O s^akd. <br />I have Ct�vp�lhr�j�nf�y}(�rgWdm$eJ"r{'?Al�r "thcL!ras r5^ M99ec�ti•Efn`3/9 dttii'e Labor Code, <br />for the perfor ance oft " u k�o6''V "rmit is issued. My workers' compensation insurance <br />carricr �i <br />Carrier: c <br />Date. <br />r <br />_ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as t becQQ���,,e� sub ect to s'ation laws of California, and agree that if I <br />should �aa�bi�td`li4� " ction 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date:— Company Nar;natur • FISCH ENVIRONMENTAL <br />Printed Name:. <br />Compan�y Address: <br />WARNING: FAILURETO SUWORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL <br />CRIMMIIN{AAL PENALTIES <br />iAND <br />�CIVIL FINES UP TO O�(�T! Ab=RS <br />PROVIDED FOR 110 SA'fT�T371�F THE LAB PENS �LEiq AGES AS <br />Company Phone Number: (209,x. -J'2-357 zed representative), hereby <br />authorize <br />C$LB License Number: 683865 <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 />5-17-20001 MI <br />