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COMPLIANCE INFO_2018
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PR0232355
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COMPLIANCE INFO_2018
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Last modified
7/6/2021 9:58:11 AM
Creation date
6/23/2020 6:55:31 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2018
RECORD_ID
PR0232355
PE
2361
FACILITY_ID
FA0000591
FACILITY_NAME
QUIK STOP MARKET #152
STREET_NUMBER
1721
Direction
S
STREET_NAME
CHEROKEE
STREET_TYPE
LN
City
LODI
Zip
95240
APN
062-060-48
CURRENT_STATUS
01
SITE_LOCATION
1721 S CHEROKEE LN # 1
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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SJGOV\kblackwell
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FilePath
\MIGRATIONS\UST\UST_2361_PR0232355_1721 S CHEROKEE_2018.tif
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EHD - Public
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F- -9 <br />iDATE <br />A� V CE TT CATE OF LIABILITY INSUR E <br />(MM/DD /YYYY) <br />3/21/2018 <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 <br />TLB Insurance Services <br />CA License #OB82095 <br />3000 Oak Road, Suite 210 <br />Walnut Creek CA 94597 <br />CONTACT Shales Pearson <br />NAME: <br />PHONE (916)691-5555 FAX N0;(888)329-8842 <br />E-MAIL shala-Pearson@leavitt.com <br />ADDRESS: <br />INSURERS AFFORDING COVERAGE NAIC # <br />INSURERA:Admiral Insruance Company a24856 <br />INSURED <br />Walton Engineering, Inc. <br />P.O. BOX 1025 <br />West Sacramento CA 95691 <br />INSURERB:Travelers Casualty Co. of America 19046 <br />INSURERC:State Compensation Insurance Fund 35076 <br />INSURERD:Travelers Casualty Co. of America 19046 <br />INSURER E: <br />INSURER F: <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 <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />MMLI POLICY POLICY <br />EXPLIMITS <br />X COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE $ 11000,000 <br />FxI <br />DAMAGE TO RENTED <br />50,000 <br />A <br />CLAIMS -MADE OCCUR <br />PREMISESEa occurrence) $ <br />MED EXP (Any one person) $ 51000 <br />X Incl. Pollution Liab. <br />FEIECC1358705 <br />3/6/2018 <br />3/6/2019 <br />X Incl. Professional Liab. <br />PERSONAL &ADV INJURY $ 11000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE $ 2,000,000 <br />POLICY � PRO- LOC <br />JECTOTHER: <br />PRODUCTS - COMP/OP AGG $ 2,000,000 <br />$ <br />1 <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT $ 1,000,000 <br />Ea accident <br />BODILY INJURY (Per person) $ <br />X ANY AUTO <br />B <br />BODILY INJURY (Per accident) $ <br />AOSCHEDULED <br />AUTOS AUTOS <br />8106K992397 <br />3/6/2018 <br />3/6/2019 <br />PROPERTY DAMAGE $ <br />Per accident <br />X X NON -OWNED <br />HIRED AUTOS AUTOS <br />UMBRELLA LIAB <br />X <br />OCCUR <br />EACH OCCURRENCE $ 10, 000, 000 <br />AGGREGATE $ 10, 000,000 <br />A <br />X <br />EXCESS LIAR <br />CLAIMS -MADE <br />DED RETENTION$ <br />$ <br />FEIEXS1358805 <br />3/6/2018 <br />3/6/2019 <br />WORKERS COMPENSATION][ <br />STATUTE I ERH <br />AND EMPLOYERS' LIABILITY Y / N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT $ 1,000,000 <br />C <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory In NH) <br />N / A <br />9113339-2017 <br />10/1/2017 <br />10/1/2018 <br />E.L. DISEASE - EA EMPLOYE $ 11000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT $ 1,000,000 <br />D <br />Inland Marine <br />3/6/2018 <br />3/6/2019 <br />Limit $ 300,000 <br />Rented, Leased or Borrowed <br />Deductible $ 2,500 <br />DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required <br />t <br />t 7 11 ��-4 �4•- <br />�„, <br />y <br />CERTIFICATE HOLDER CANCELLATION HEAU %`° L",- <br />ACORD 25 (2014/01) <br />INS025 (201401) <br />©1988-2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />TO Whom it May Concern <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />Shala Pearson/SHPEAR <br />ACORD 25 (2014/01) <br />INS025 (201401) <br />©1988-2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />
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