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R1® CERTIFIC.. (E OF LIABILITY INS URA. - .+E oPID cl DATE (MM/DDM 06/09/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the ce cats holder is an ADDITIONAL INSURED, the pollcy(lesj must 66 endorsed. , su act to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER George Petersen Ins Agency P. O. Box 3539 NAME. PHONE FAX -V Ext): _ _(-N_F)- -- 627 College Avenue Santa Rosa CA 95402 Phone:707-525-4150 Fax:707-525-4175 ADDRESS:µ— CUSTOMERIDN: SERVIOI -- - - - INSURER($) AFFORDING COVERAGE NAIC9^ INSURED INSURER A: Cypress Insurance COmpan --� Service Station Systems, Inc. 680 Quinn Avenue ENSURER 6 INSURER C: San Jose CA 95112 INSURER D: I I E: MED EXP (Any one person) -INSURER INSURER F PERSONAL & ADV INJURY $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L1'R TYPE OF INSURANCE INSR I Wvol POLICY NUMBER �(MMlDD/YYYY) kMM1DDNYYY) LIMITS GENERAL LIABILITY ( EACH OCCURRENCE S PREMISES Ea oaaurence ----- S COMMERCIAL GENERAL LIABILITY CLANS11AADE OCCUR I I MED EXP (Any one person) 3 PERSONAL & ADV INJURY $ - ! I PRODUCTS-COMPIOP AGG S _ S___._.___.—.___.__.__.___. GEN'L AGGREGATE LIMIT APPLIES PER:i -_, PRO- I POLICY JET I LOC I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO i (Ee accident) BODILY INJURY (Per person SALL OWNED AUTOS I ------- -- - - .-) BODILY INJURY (Per a - S ' SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS � i , PROPERTY DAMAGE (Per ecadent) ----�---_A--. S S i ' UMBRELLA L1AaHCLAIMS-MADE LIAB OCCUR � EACH OCCURRENCE (5 AGGREGATEEXCESS f� J DEDUCTIBLE �_ . RETENTION b A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY_.L ANY PROPRIETORIPARTNER/EXECUTIVYI1 OFFICERmEMBER EXCLUDED? u (Mandatory In NH) RIA 3310020636101 I II 06/04/10 106/04/11 I i{�T„oYLIMt_TSy ER E.L EACH ACCIDENT i $1000000 E.L. DISEASE - EA EMPLOYEE $1000000 - E.L. DISEASE -POLICY LIMIT 51000000 Ifyes,descnbeunder DESCRIPTION OF OPERATIONS below i � I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more apace D required) Proof of coverage .�nl nru CANCELLATION VCRIirIVM1C rev �.v�� ----' --- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVIMNS. AUTHORIZED REPRESENTATIVE Proof of Coverage 0 1988-2609 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD