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Certiticate of Workers Compensation Insurance <br /> THIS IS TO CERTIFY TO East Bay Municipal Utility District (EBMUD) <br /> Dept <br /> 2130 Adeline Street <br /> P.O. Box 24055 <br /> Oakland, California 94623 <br /> TF;c FULL 3niNG DESCRIBED POLICY HAS BEEN ISSUED TO: <br /> Insured <br /> Address <br /> LOCATION AND <br /> DESCRIPTION OF PROJECT/AGREEMENT: <br /> Excavation, removal , and disposal of old fuel tanks from EBMUD locations. <br /> • <br /> TYPE OF INSURANCE Worker's Compensation Insurance as required by California State Law <br /> INSURANCE COMPANY. <br /> POLICY NUMBER <br /> POLICY TERM. From To <br /> The policy will not be cancelled nor materially altered without 30 days written notice to East Bey Municipal Utility District <br /> at the address above. <br /> IT IS HEREBY CERTIFIED the above policy provides iswrance as required by the contract dated <br /> between East Bay Municipal Utility District and the Insured. <br /> Signed <br /> Authonzed Signature of Broker,Agent or Underwriter <br /> Date Form <br /> • Address <br /> Phone <br /> N-17 • 2186 <br />