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02-78 May 29, 2002
RESOLUTION NO.: DATED:
I
A RESOLUTION AUTHORIZING APPLICATION
TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA
FOR A CERTIFICATE OF CONSENT TO SELF INSURE
WORKERS' COMPENSATION LIABILITIES
At a meeting of the Board of D eon s
(enter title)
of the M.idpen-inauta Reaionat Open Sauce N,-%t .i ct
(enter name of public agency,district)
a Spec t.a.e D-czttiet organized and existing under the laws of tie State of California,
(enter type of agency)
held on the 29th day of May $Q02 ,the fo lowing resolution
was adopted:
RESOLVED,that the Genenat Manageh
(enter position titles)
be and they are hereby severally authorized and empowered to make application to the Director of Industrial
Relations,State of California,for a Certificate of Consent to Self Insure workers'compensate n liabilities
on behalf of the
Mid en,i.rsuat Re .i.ona.Q. Open Space D-iztAict
(enter name of district)
and to execute any and all documents required for such application.
1 C. Deane L ttt e the undersigned PrLu ide!g
(enter name) (enter tit e)
of the Board of the said M t�
(enter name of agency)
S ec.i.at Di,6tt r�i,ct Pne�.i.de
a p , hereby certify that I am the
(enter type of agency) (enter itle)
of said DiA tAic t ,that the foregoing is a full,true and corr et copy of the
(enter type of agency)
resolution duly passed by the Board at the meeting of said Board held on the day and at the p ace therein specified
and that said resolution has never been revoked,rescinded,or set aside and is now in full force and effe t.
IN WITNESS WHEREOF: I HAVE SIGNED MY NAME AND AFFIXED THE SEAL OF HIS
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