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; <br />09/21/2007 18:42 9166385611 CASCADEDRILLING <br />Sep. 21. 2007 4:2BPM Advanced GeoEnvronmental <br />PAGE 02/134 <br />NO, 1DLL H L <br />San San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS:J q 7g1 74Jiz o PERMIT SR#: 6c2- I LO <br />Lj iC4 <br />LICENSED CONTRACTORS DECLARATION (1,.CD) <br />I 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 />— <br />LiCens6*! Lxpiration Date; 0 <br />Date: Cantrector: C'ef ‘/1 <br />0J') V417 • Signature!. <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I tlereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />_ I have end will maintain a certificate 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 />..*.‘ <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 />Carder: , 0- V-..-- rli)ri 0 ;A.A., 1 <br />I certify that In the performance of the work for which thls permit is issued, 1 shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that If I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions, <br />Expiration Date:c —\ Signature! <br />Printed Name: -ro n -.3 6Lrirek NA o <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND ClVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSM1ON, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1. <br />hereby authorize (print name) -TIM Cki ell R. R At G- Mc.r <br />to nIgn thlg San Joaquin County Well Permit Application on my behalf. I understand thls authorization is valid for <br />one (1) year and Is limited to the work plan dated on the front page of this application. <br />8-4-02 I Mi <br />END 29-02-001 <br />etnn 01 <br />Policy Number: 07 -e-v\ig,3oE,-3 <br />(signature ofC.57 licensed authorized representative),