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Date: S Signature: <br />Printed Name: <br />08/25/2000 FRI 13:42 FAX 916 777 4101 V W DRILLING INC <br /> 002 <br />JAL, Taw° <br />San Joaquin County Environmental 'Health Services, Unit IV Well Permit Application Supplement <br />JQB ADDRESS:L2?)50 IOC): Cg_L,..t) PERMIT SR#: P0Z-5 ?2-G <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Dtvision <br />3 of the Business and Professions Code and my license is in fUll force and effect. <br />License #: r7c90641-1 ExpiraIion Date: LIA3o/oa <br />Date ontractor: V_Lj DTI 0/(5 <br />1-d-2-Z-11-9 <br /> <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the foliowing 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 />v/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 LepYY&1 k*. Policy Number:I I3-9 9 Lull+ op.5334 <br />I certify that in the performance of the work for which this permit is issued, shall not employ any person in <br />any manner so as to become sub)ect to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Se 'on 3700 of the Labor Code. I shall <br />forthwth co ply with those provisions, <br />Cht4 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDIT/ON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE. <br />(C-57 licensed authorized representative), hereby <br />authorize A <br />to sign thls San oaquin County Well Permit Application on my behalf. l understand tills authorization Is valid for <br />_one (1 )year and is limited to the work plan dated on the front page of this application. <br />Signature: <br />Printed name: j0 <br />eAtA-V-' <br />VIUJ NV75'Lli F-;F:Et-Pa-1 <br />E