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COMPLIANCE INFO_2009-2012
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2300 - Underground Storage Tank Program
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PR0231074
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COMPLIANCE INFO_2009-2012
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Last modified
3/1/2023 11:20:58 AM
Creation date
6/23/2020 6:41:02 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2009-2012
RECORD_ID
PR0231074
PE
2361
FACILITY_ID
FA0002541
FACILITY_NAME
7-ELEVEN INC #20632
STREET_NUMBER
4627
STREET_NAME
DA VINCI
STREET_TYPE
DR
City
STOCKTON
Zip
95207
APN
11002003
CURRENT_STATUS
01
SITE_LOCATION
4627 DA VINCI DR
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0231074_4627 DA VINCI_2009-2012.tif
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EHD - Public
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E(MMIDDIYYYY <br /> A`�®® CERTIFICATE OF LIABILITY INSU NCE D F3/21/2018 ) <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to <br /> the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT Shale Pearson <br /> NAME: <br /> TLB Insurance ServicesPHONE E>a.Services (916)691-5555 FAX'JCNe: (868)329-8842 <br /> CA License #0882095 AIL <br /> ADDRESS:shala-pearson@leavitt.com <br /> 3000 Oak Road, Suite 210 INSURERS AFFORDING COVERAGE NAIC# <br /> Walnut Creek CA 94597 INSURERAAdmiral Insruance Company a24856 <br /> INSURED INSURERB:Travelers Casualty Co. of America 19046 <br /> Walton Engineering, Inc. INSURERC:State Compensation Insurance Fund 35076 <br /> P.O. Box 1025 INSURERD:Travelers Casualty Co, of America 19046 <br /> INSURER E: <br /> West Sacramento CA 95691 INSURERF: <br /> COVERAGES CERTIFICATE NUMBER:18/19 All Policies REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR ADDL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE POLICY NUMBER IMM22MM IMMIDDIYYYYI LIMITS <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> A CLAIMS-MADE OCCUR DAMAGETORENTED 50,000 <br /> IS <br /> Ea occurrence $ <br /> X Incl. Pollution Liab. FEIECC1358705 3/6/2018 3/6/2019 MED EXP(Any one person) $ 5,000 <br /> X Incl. Professional Liab. PERSONAL&ADV INJURY $ 1,000,000 <br /> GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> Ea accident 1,000,000 <br /> B X ANY AUTO BODILY INJURY(Per person) $ <br /> ALL OWNED SCHEDULED 8106K992397 3/6/2018 3/6/2019 BODILY INJURY(Peraccident $ <br /> AUTOS AUTOS ) <br /> NON-OWNED P 0P.E tl nt DAMAGE $ <br /> X HIRED AUTOS X AUTOS <br /> UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ _10,000,000 <br /> A X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 <br /> DED I I RETENTION$ IFEIEXS1358805 3/6/2018 3/6/2019 $ <br /> WORKERS COMPENSATION X PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 1,000,000 <br /> OFFICER/MEMBER EXCLUDED? � N/A <br /> C (Mandatory in NH) 9113339-2017 10/1/2017 10/1/2018 1 E.L.DISEASE-EA EMPLOYE $ 1,000,000 <br /> If yes, scribe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 <br /> D Inland Marine 3/6/2018 3/6/2019 Limit <br /> $ 300,000 <br /> Rented, Leased or Borrowed Deductible <br /> $ 2,500 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> To Whom it May Concern THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> Shala Pearson/SHPEAR <br /> ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br /> INS025(201401) <br />
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