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i <br /> I <br /> TRUCKED NON-HAZARDOUS WASTE DISPOSAL PERMIT <br /> Terms and Conditions <br /> Addendum D <br /> CERTIFICATION OF WORKERS' COMPENSATION INSURANCE <br /> f EBMUD - <br /> THIS IS TO CERTIFY TO: East Bay Municipal Utility D!strict(EBMUD) <br /> Department: Environmental Seivices Division <br /> Street Address: 375—1'IStreet.MS#702 <br /> Mailing Address: P.O.Box 24055 <br /> City,State,Zip: Oakland,CA 94623 <br /> THE FOLLOWING DESCRIBED POLICY HAS BEEN ISSUED TO: <br /> District Permit Number: <br /> (Completed by EBMUD) <br /> Insured: <br /> Address: <br /> LOCATION AND DESCRIPTION OF PROJECT/AGREEMENT: <br /> Trucked non-hazardous waste permitted for disposal at designated EBMUD Wastewater Treatment facilities <br /> TYPE OF INSURANCE: Workers'Compensation Insurance as required by California State Law, <br /> INSURANCE COMPANY: <br /> POLICY NUMBER: 2S <br /> POLICY From: To: <br /> TERM: 1,A 11 1 OCI 1 <br /> The policy will not be canceled nor the above coverage reduced <br /> without 30 days written notice to East Bay Municipal Utility District at <br /> the address above. <br /> IT IS HEREBY CERTIFIED the above policy provides insurance as <br /> required by the agreement between East Bay Municipal Utility District <br /> I at the Insured. <br /> i <br /> Signed: <br /> Date: J I Firm: -- <br /> s <br /> 4 <br /> Address <br /> Phone: <br /> "This certificate or verification of Insurance is not an Insurance policy and does not amend,extend,or alter the coverage afforded by the <br /> policies iksted herein. Notwithstanding any requirement,term or conditions of any contract or other document with respect to whlch thls <br /> certificate or verification or insurance maybe issued or may pertain,the insurance afforded by the policies described herein is subject to all <br /> the terms,exclusions,and condltions of the olicies;' <br />