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COMPLIANCE INFO_2019
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0515864
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COMPLIANCE INFO_2019
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Last modified
11/25/2020 6:53:08 PM
Creation date
9/24/2020 9:39:42 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2019
RECORD_ID
PR0515864
PE
2361
FACILITY_ID
FA0012355
FACILITY_NAME
A&A GAS FOOD MART
STREET_NUMBER
1330
Direction
E
STREET_NAME
YOSEMITE
STREET_TYPE
AVE
City
MANTECA
Zip
95336
APN
22120053
CURRENT_STATUS
01
SITE_LOCATION
1330 E YOSEMITE AVE
P_LOCATION
04
P_DISTRICT
005
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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POLICYHOLDER COPY NE <br /> STATE <br /> COMPENSATION P. O. BOX 8192, PLEASANTON, CA 94588 <br /> INSURANCE <br /> FUND <br /> CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> ISSUE DATE : 11 - 01 - 2018 GROUP: <br /> POLICY NUMBER: 1308371 - 2018 <br /> CERTIFICATE ID: 173 <br /> CERTIFICATE EXPIRES: 11 - 01 - 2019 <br /> 11 - 01 - 2018 / 11 - 01 - 2019 <br /> CONTRACTORS STATE LICENSE BOARD NE LIC PERMIT {{ : 804904 <br /> INCEPTION DATE : 11 - 01 - 2018 <br /> PO BOX 26000 DO : NE <br /> SACRAMENTO CA 95826 - 0026 <br /> This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br /> California Insurance Commissioner to the employer named below for the policy period indicated. <br /> This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br /> by the policy listed herein, Notwithstanding any requirement, term or condition of any contract or other document <br /> with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance <br /> afforded by the policy described herein is subject to all 'the terms, exclusions, and conditions, of such policy. <br /> Authorized Representative President and CEO <br /> EMPLOYER ' S LIABILITY LIMIT INCLUDING DEFENSE COSTS : $ 1 , 000 , 000 PER OCCURRENCE . <br /> ENDORSEMENT 312085 ENTITLED CERTIFICATE HOLDERS ' NOTICE EFFECTIVE 11 - 01 - 2016 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY . <br /> EMPLOYER <br /> CONFIDENCE UST SERVICES INC . NE <br /> 16250 MEACHAM RD <br /> BAKERSFIELD CA 93314 <br /> M0409 <br /> PRINTED 10 - 17 - 2018 <br /> IREVJ • 2014) <br />
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