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A4 O` SERVSTA-01 , fit <br />04 . CERTIFICATE OF LIABILITY 1 DATE(MMIDD/YY <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGNTS UPON THE CERTIFICATE HOLD12012 <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICi <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIA <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to 1 <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER License S 0603247 c <br />George Petersen Insurance Agency, Inc. E' <br />P.O. x 3539 PMoeE : (800) 236-9046 <br />Santa Rosa, CA 95402 a� as : (888) 579-274; <br />A :ICW <br />Service Station Systems, Inc. <br />680 Quinn Ave <br />San Jose, CA 95112 <br />_-_CE LI 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 PERipi <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THII <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 />'BR TYPE OF INSURANCE 80LICY NUMBER <br />I GENERAL LIABILITY I I ] /MMIDD/YYYYI tiaMIDOM YY► LIMITS <br />fMERCiAL GENERAL LIABILITY <br />CLAIMS -MADE F-� OCCUR <br />GENM AGGREGATE LIMIT APPLIES PER: <br />AUTOMOBILE LIABILITY <br />ANY AUTO <br />LL ED <br />ULED <br />AALLt <br />r <br />AUTOS <br />HIRED AUTOS <br />pSED <br />UMBRELLA LIAR <br />OCCUR <br />EXCESS LIA8 <br />,,, <br />AND EMPLOYERS' LIABILITY <br />A ANY PROPRIETORIPARTNERIEXECUTIVE YIN <br />OFFICERIMEMBER EXCLUDED? Q INIA <br />(Mandatory M NMI <br />30700 1 6/4/2012 1 6/4/2013 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, N nwre space is required) <br />'roof of coverage <br />CERTIFICATE HOLDER <br />Proof of Coverage <br />I <br />ACORD 25 (2010/05) <br />EACH <br />MED EXP (AnY one person) 1 $ <br />INJURY <br />BODILY INJURY (Per person) _ S <br />BODILY INJURY (Per aa�dent) $ <br />Pe �denDA"AA E $ <br />S <br />EACH OCCURRFWM: e <br />EACH <br />E.L. DISEASE . EA <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />2010 ACORD CORPTION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD ORA <br />