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FIELD DOCUMENTS_FILE 2
EnvironmentalHealth
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3500 - Local Oversight Program
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PR0545028
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FIELD DOCUMENTS_FILE 2
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Last modified
12/6/2019 5:08:09 PM
Creation date
12/6/2019 2:54:13 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
FIELD DOCUMENTS
FileName_PostFix
FILE 2
RECORD_ID
PR0545028
PE
3528
FACILITY_ID
FA0003919
FACILITY_NAME
VAN DE POL ENTERPRISES
STREET_NUMBER
5491
STREET_NAME
F
STREET_TYPE
ST
City
BANTA
Zip
95304
CURRENT_STATUS
02
SITE_LOCATION
5491 F ST
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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66 1' i'1f;05 17: 51 7073745677 <br /> ('ODOD14ARD DRILLlNIi <br /> amu.LC)CJJ ti-H; 1f`Ic r NG.709 P.6 <br /> z <br /> CON'TRACTOR'S]ENDORSEMENT <br /> Folder No.02324-65 <br /> A. As a condition to entering upon Licensor's right-Of-WRY to perform work pursuant to this <br /> Agreement;Licensee's contractor(Fill in): <br /> ti71-S Tom, G14 `T .s' 7 1 <br /> (haminafter"Contractor") agrees to comply with all tie terms and provisions of this A.greern=t relating <br /> to the wort:to be pmfonncd and,the insurance requirements sat forth in Exhibit A-1. <br /> B. Before the Contractor commences any worlq the Contractor will pay the Licensor a <br /> nonrefundable paytaant of$500 upon execution and Mian of this Contractor's Endorsement, and will <br /> provide the Licensor with a. certificate issued by its insurance eatrier providing the insurance coverage <br /> required pursuant to Exhibit A-1 in a policy which contains the following type endorsement: <br /> UNION PACIFIC RAILROAD COMPANY is named as an additional insured <br /> with respect to all liabilities arising out of I:nsured's performance of work on behalf of the <br /> Liocnsee, <br /> All insurance correspondence shall be direotnd to: Ion E. Devish - Folder No. 02324-65, Union Pacific <br /> Railroad Company, 1400 Drniglas Street STOP 1690,Omaha,Nebraska 68179-1690. <br /> - (Please print Contractor's Name above) <br /> Title: <br />
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