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COMPLIANCE INFO_2013-2016
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2300 - Underground Storage Tank Program
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PR0517272
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COMPLIANCE INFO_2013-2016
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Last modified
6/30/2020 10:41:44 AM
Creation date
6/23/2020 6:59:27 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2013-2016
RECORD_ID
PR0517272
PE
2361
FACILITY_ID
FA0012979
FACILITY_NAME
FLYING J TRAVEL PLAZA #617
STREET_NUMBER
15237
Direction
N
STREET_NAME
THORNTON
STREET_TYPE
Rd
City
Lodi
Zip
95242
APN
02519014
CURRENT_STATUS
01
SITE_LOCATION
15237 N Thornton Rd
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0517272_15237 N THORNTON_2013-2016.tif
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EHD - Public
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C <br />JONECOV-02 KUNCES <br />A4cc>m r'Q p p <br />�..,.,� CERTIFICATE LIABILITY INSURANCE <br />DATE (MM/DD/YYYY) <br />7/2/2013 <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 <br />IOA Insurance Services-ORG <br />130 Vantis, Suite 250(AIC, <br />AIISO VIQJO, CA 92656 <br />NAME: CONTACT Celeste Garcia <br />PHONE FAX <br />A/C No Extl: (949) 297-5962 A/C No): (949) 297-5960 <br />E-MAIL arciat <br />lese. l <br />ADDRESS: ceg oausa.com <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURER A: OneBeacon Insurance Company 21970 <br />INSURED <br />Jones Covey Group, Inc. <br />9595 Lucas Ranch Road Ste 100 <br />Rancho Cucamonga, CA 91730 <br />INSURER B: Peerless Insurance Company 24198 <br />INSURER C: Granite State Ins Co 23809 <br />INSURER D: <br />INSURER E: <br />INSURER F : <br />COVERAGES CERTIFICATE NUMBER: 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 />INSR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD <br />POLICY EXP <br />MM/DD/YYYY <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE $ 5,000,000 <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />7930001440002 <br />71112013 <br />7/1/2014 <br />DA PREMISES Ea occuence $ 50,000 <br />CLAIMS -MADE ® OCCUR <br />MED EXP (Any one person) $ 5,000 <br />PERSONAL & ADV INJURY $ 5,000,000 <br />GENERAL AGGREGATE $ 5,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS - COMP/OP AGG $ 5,000,000 <br />$ <br />POLICYFX PROJECT LOC <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT 1,000,000 <br />Ea accident $ <br />BODILY INJURY (Per person) $ <br />B <br />X ANY AUTO <br />BA8853096 <br />7/1/2013 <br />7/1/2014 <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY (Per accident) $ <br />PROPERTY DAMAGE $ <br />PER ACCIDENT <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />UMBRELLA LIAB <br />X <br />OCCUR <br />EACH OCCURRENCE $ 2,000,000 <br />AGGREGATE $ 2,000,000 <br />A <br />X <br />EXCESS LIAB <br />CLAIMS -MADE <br />7930001450002 <br />7/1/2013 <br />7/1/2014 <br />DED RETENTION $ <br />$ <br />C <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N <br />WC009970790 <br />2/112013 <br />2/1/2014 <br />X I WC STATU- OTH- <br />TORY LIMITS ER <br />E.L. EACH ACCIDENT $ 1,000,000 <br />OFFICERIMEMBER EXCLUDED? ❑ <br />(Mandatory in NH) <br />N / A <br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT $ 1,000,000 <br />A <br />Professional Liab. <br />7930001440002 <br />7/1/2013 <br />7/1/2014 <br />Limit: 5,000,000 <br />A <br />Pollution Liab. <br />7930001440002 <br />7/1/2013 <br />7/1/2014 <br />Limit: 5,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) <br />30 Days Notice of Cancellation with 10 Days Notice for Non -Payment of Premium in accordance with policy provisions. <br />CERTIFICATE HOLDER CANCELLATION <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD <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 />EVIDENCE OF INSURANCE <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD <br />
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