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COMPLIANCE INFO_2022
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0507837
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COMPLIANCE INFO_2022
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Entry Properties
Last modified
1/13/2023 9:25:07 AM
Creation date
3/24/2022 4:04:26 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2022
RECORD_ID
PR0507837
PE
2361
FACILITY_ID
FA0008057
FACILITY_NAME
H&S ENERGY PRODUCTS, LLC 3084
STREET_NUMBER
3940
Direction
N
STREET_NAME
TRACY
STREET_TYPE
BLVD
City
TRACY
Zip
95304
APN
21220004
CURRENT_STATUS
01
SITE_LOCATION
3940 N TRACY BLVD
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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ACID CERTIFICATE OF LIABILITY INSURANCE FDA7TE (MMIDDNIYYY)OIOZO <br /> 03/02/2022 <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 have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT Shala Pearson <br /> NAME: <br /> TLB Insurance Services AHCNE Ext : (916) 790-5863 a/c Nu : (888) 329-8842 <br /> CA License #01382095 E-MAIL shala-pearson@leavitt.com <br /> ADDRESS: <br /> 2358 Maritime Dr, Ste 100 <br /> INSURER(S) AFFORDING COVERAGE NAIC # <br /> Elk Grove CA 95758 INSURERA : Admiral Insurance Company 24856 <br /> INSURED INSURER B : Travelers Property Casualty Company of America 25674 <br /> Walton Engineering , Inc. INSURER c : Service American Indemnity Company 39152 <br /> P.O. Box 1025 INSURER D : Travelers Property Casualty Company. 36161 <br /> INSURER E : <br /> West Sacramento CA 95691 INSURER F : <br /> COVERAGES CERTIFICATE NUMBER: 22/23 Master REVISION NUMBER: <br /> THIS IS TO CERTIFY THATTHE 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 TYPE OF INSURANCE POLICY EFF POLICY EXP <br /> LTR INSD WVD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 , 0001000 <br /> CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 50, 000 <br /> PREMISES Ea occurrence $ <br /> X Inc. Pollution Liability 5 , 000 <br /> MED EXP An one person) $ <br /> A X Inc. Professional Liability FEIECC1358708 03/06/2022 03/06/2023 PERSONAL & ADV INJURY $ 1 ,000 ,000 <br /> GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $ 2,0000000 <br /> POLICY PRO LOC <br /> 2,000 ,000 <br /> JECT PRODUCTS $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 11000,000 <br /> Ea accident <br /> X ANYAUTO BODILY INJURY (Per person) $ <br /> B OWNED SCHEDULED 8108L785302 03/06/2022 03/06/2023 BODILY INJURY (Per accident) $ <br /> AUTOS ONLY AUTOS <br /> X HIRED �/ NOWOWNED PROPERTY DAMAGE $ <br /> /� AUTOS ONLY X AUTOS ONLY Per accident <br /> Uninsured motorist $ 1 , 000 ,000 <br /> UMBRELLA LIAB "v" """ '�� <br /> X OCCUR EACH OCCURRENCE $ 10, 000, 000 <br /> A X EXCESS LIAB CLAIMS-MADE FEIEXS1358808 03/06/2022 03/06/2023 AGGREGATE $ 100000, 000 <br /> DED I X1 RETENTION $ 0 $ <br /> WORKERS COMPENSATION X SPER <br /> TATUTE OT <br /> ERH <br /> AND EMPLOYERS' LIABILITY YIN <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 11000,000 <br /> C OFFICERIMEMBEREXCLUDED9 FN N / A SAMTWC10020100 10/01 /2022 10/01 /2023 <br /> (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 11000,000 <br /> If yes, describe under 1 , 000,000 <br /> DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ <br /> Inland Marine <br /> D Leased/Rented/Borrowed 66081<816207 03/06/2022 03/06/2023 Limit $300, 000 <br /> Deductible $2, 500 <br /> DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <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 /> To Whom it May Concern Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> © 1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />
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