Reso 2004-685RESOLUTION NO. 2004 -685
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 Directors of the Costa Mesa Sanitary District, a
Special District organized and existing under the laws of the State of California,
held on the 23rd day of June 2004, the following resolution was adopted:
RESOLVED that the President and Secretary 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' compensation liabilities on behalf of the Costa Mesa Sanitary
District and to execute any and all documents required for such application.
I, Arlene Schafer, the undersigned President of the Board of the said Costa
Mesa Sanitary District, a Special District, hereby. certify that I am the President of
said Special District, that the foregoing is a full, true and correct copy of the
resolution duly passed by the Board at the meeting of said Board held on the day
and at the place therein specified and that said resolution has never been revoked,
rescinded, or set aside and is now in full force and effect.
IN WITNESS WHEREOF: I HAVE SIGNED MY NAME AND AFFIXED THE
SEAL OF THIS SPECIAL DISTRICT
THIS 23RD DAY OFJUNE 2004.
J es Ferr ,Man, Secret rye
STATE OF CALIFORNIA)
COUNTY OF ORANGE ) ss
CITY OF COSTA MESA )
I, JOAN REVAK, Clerk of the Costa Mesa Sanitary District, hereby certify
that the above and foregoing Resolution No. 2004 -685 was duly and regularly
passed and adopted by said Board of Directors at a regular meeting thereof held
on the 23rd day of June 2004.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal
of the Costa Mesa Sanitary District this 23rd day of June 2004.
7 14A, z
Clerk of t ..CA`s #a Vfesa Sanitary District
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