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PAGE 03 <br />PAGE OS <br />09/18/2001 08:48 7073745677 <br />/15/2001 11:49 209-579-2225 • <br />—San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement/ <br />JOB ADDRESS: 14-4- PERMIT $R#: <br />LICENSED CONTRACTOR'S DECLARATION (LCD) <br />hereby af IT that I am licensed under the provisionsof Chapter g (commencing with Section 7000) of Division <br />3 of the Business and Professions Coda and my license is in full force and effect <br />License*. ..-S7 °' 7 I 0039 <br />Date: 1-let _01 Contractor: .(A3OPIPJAP <br />Expiratic, r)te: 2- <br />Signature: <br />Printed Man16: 6-1elx.• traeSS reo b4-\ <br />Title: <br /> <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL. THAT APPLY) <br />have and will maintain a certificate of consent to self-Insure for workers compensation. as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued <br />4. <br />. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: 67IAMr45 PON)6 Policy Number: 00 2.62 a <br />I certify that in the performance of the. work for which this pormit is issued. I shall not employ any person in <br />any manner so as to become subiect to the workers' compensation laws of California, and agree that if I <br />shoutd become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions, <br />Data: -/ EI Signature: <br />Printed Name: exi,e., 7 -02.004-7 <br />WARNING: FAJLURE TO SVOLJR4 WORKERS' COMPENSATIoN COVeRAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOY2R TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(si mod), IN 41)01110N TO THE COST OF COMPENSATION, NTEREST, A.TTORNErS FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />4-rehe rocs$ nee;4•1 <br />authoriu e`bizAde CQr-% CE. 112.. SE. <br /> <br />(C-57 licensed authorized representative), hereby <br /> <br />to sign eats San Joaquin County Well Permit Application on my behalf. I understand 0,4 authorization Is valid for <br />on* <br /> <br />1) yonPririlfrifinitted to the work plan datDe, on the front page of 4 his application. <br />I 547.2005 1 MI <br />WOODWARD DRILLING CO <br />MODEVO faC