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COMPLIANCE INFO_2016
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0505264
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COMPLIANCE INFO_2016
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Last modified
8/11/2021 10:45:06 AM
Creation date
6/23/2020 6:57:24 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2016
RECORD_ID
PR0505264
PE
2361
FACILITY_ID
FA0006672
FACILITY_NAME
FLYING J TRAVEL PLAZA #618*
STREET_NUMBER
1501
Direction
N
STREET_NAME
JACK TONE
STREET_TYPE
RD
City
RIPON
Zip
95366
APN
22811017
CURRENT_STATUS
01
SITE_LOCATION
1501 N JACK TONE RD
P_LOCATION
05
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0505264_1501 N JACK TONE_2016.tif
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EHD - Public
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JONECOV-02 DADACAYA <br /> A'eQRAIX CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> 6/24/2016 <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 License#OE67768 CONTACT <br /> NAME: <br /> IOA Insurance Services PHONE FAX <br /> 130 Vantis (AIC' <br /> AIC No Ell:(949)297-5962 A/c No:(949)297-5960 <br /> Suite 250 E-MAIL <br /> Aliso Viejo,CA 92656 ADDRESS: <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A:Colony Insurance Company 39993 <br /> INSURED INSURER B:Philadelphia Indemnity Insurance Company 18058 <br /> Jones Covey Group,Inc. INSURER C:Everest National Insurance Company/ 10120 <br /> 9595 Lucas Ranch Rd Ste 100 INSURER D <br /> Rancho Cucamonga,CA 91730 INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: REVISION UMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAM ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DO CU NT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED H EIN IS SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TypE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS <br /> LTR INSD POLICY NUMBER MM/DD MMIDD <br /> A X COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE $ 5,000,00 <br /> CLAIMS-MADE Al OCCUR PACE305425 07/0112016 07/01/201 DAMAGE300,00 <br /> PREMISES Ea occurrence $ <br /> MED EXP(Any one person) $ 25,00 <br /> PERSONAL&ADV INJURY $ 5,000,00 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,00 <br /> POLICY®JE LOC <br /> PRODUCTS-COMP/OP AGG $ 5,000,000 <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 <br /> Ea accident <br /> B ANY AUTO PHPK1514144 07/01/201§ 07/01/2017 BODILY INJURY(Per person) $ <br /> AALL <br /> UTOS OWNED X SCHEDULED f/ BODILY INJURY(Per accident) $ <br /> AUTOS <br /> XX NON-OWNED J PROPERTY DAMAGE $ <br /> HIRED AUTOS AUTOS // Per accident <br /> UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,00 <br /> A X EXCESS LIAB CLAIMS-MADE EXC305426 0701/2016 07/01/2017 AGGREGATE $ 2,000,00 <br /> DED FX FETENTION$ 0 1� $ <br /> WORKERS COMPENSATION X PER I OTH- <br /> AND EMPLOYERS'LIABILITY STATUTE ER <br /> C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/Y❑N NIA CA10002046161 ;' 05101/2016 05/01/2017 E.L.EACH ACCIDENT $ 1,000,00 <br /> OFFICER/MEMBER EXCLUDED? <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 <br /> A Professional Liab. PACE305425 07/01/2016 07/01/2017 5,000,00 <br /> A Contractors Poll. PACE305425 07/01/2016 07/01/2017 5,000,00 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) <br /> Proof of Coverage. <br /> f <br /> r' <br /> 1` <br /> r� <br /> CERTIFICATE HOLDER CANCELLATION <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 /> AUTHORIZED REPRESENTATIVE <br /> G <br /> ©1988-2014 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD <br />
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