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STATE <br />P.O. BOX 807, SAN FRANCISCO, CA 84101.0807 <br />corNpoll NSATI®N <br />1NSUR ANCa <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />t dZiRUARY 19` 1991 <br />POLICY NUMBER: <br />CERTIFICATE EXPIRES: <br />r <br />CCu':'Y OF SAN JCAQUIN <br />PU8LIC HEALTH SERVICES <br />P 0 SOX 952001 <br />STOCKT4N< CA 95201 <br />110 <br />JO:sa C:NTkACT LI`Ei,SE 9.:?,'3417 <br />ALL J J -S I'l COUNTY <br />This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California <br />Insurance Commissioner to the employer named below for the policy period indicated. <br />This policy is not subject to cancellation by the Fund except upon trsn,days' advance written notice to the employer. <br />We will also give you TJM days' advance notice should this policy be cancelled prior to its normal expiration. <br />This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the <br />policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions and conditions of such policies. <br />PRESIDENT <br />E%vD0RSE;"ENT ;2255 'ENTITLED C:RTIFICATE HCLDEF"S' ;�T.CE rFF,'CT`,J= <br />G3/05/91 IS ATTACHE0 TO AND FOR.; A FART OF THIS POLICY. <br />EMPLOYER <br />r <br />0% cGU'LPMENT SERVICE DT.VILST.ON OF <br />10EITri A TALLIAI INC <br />P 0 1S.Ox 450 <br />SAN o4NDHEA's CA 95249 <br />L. <br />SCIF 10262 (REV. 10-86) COPY FOR INSUREDS FILE no n OFaa <br />