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COMPLIANCE INFO_2018
Environmental Health - Public
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EHD Program Facility Records by Street Name
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2300 - Underground Storage Tank Program
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PR0526212
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COMPLIANCE INFO_2018
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Entry Properties
Last modified
7/21/2020 9:26:53 AM
Creation date
9/4/2018 1:38:02 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2018
RECORD_ID
PR0526212
PE
2351
FACILITY_ID
FA0017737
FACILITY_NAME
CHEVRON STATION #307709*
STREET_NUMBER
10858
STREET_NAME
TRINITY
STREET_TYPE
PKWY
City
STOCKTON
Zip
95219
APN
06602015
CURRENT_STATUS
01
SITE_LOCATION
10858 TRINITY PKWY
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
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EHD - Public
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TOWNC-1 OP ID: JK <br />CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MMIDDIYYYY) <br />10119/2017 <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 Ileu of such endorsement(s). <br />PRODUCER 530-626-2533 <br />ISU Insurance Services <br />Atwood Agency <br />600 Pacific Street <br />CONTACT Jennifer L. Kime <br />PHONE530-626-2533 FAX 530-622-5221 <br />(AIC, No, Ext): (A/C, No): <br />AEb-1,ARILE,S,jkime@atwoodins.com <br />Placerville, CA 95667 <br />1011912017 <br />I <br />Jennifer L. Kime <br />INSURERS AFFORDING COVERAGE I NAIC q <br />INSURER A: Homeland Ins Co of NY <br />MED EXP (Any one mon S 5,000 <br />INSURED Town & Country Contractors Inc <br />3206 Luyung Drive <br />Rancho Cordova, CA 95742 <br />INSURERS State Compensation Ins Fund 35076 <br />INSURER C West American Insurance Co 44393 <br />INSURER D, <br />PRODUCTS - COMP/OP AGG 1 S 2,000,000 <br />INSURER E: <br />C <br />INSURER F: <br />Cr1VFRAGES C-ERTIFICATF N1IMRFR- 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 />I TR <br />TYPE OF INSURANCE <br />DDL <br />UBR <br />POLICY NUMBER I <br />POLICY EFF <br />POLICY EXP <br />MIDDrYYYYI <br />LIMITS <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE ❑X OCCUR <br />7930026880003 <br />j <br />1011912017 <br />I <br />10/19/2018 <br />EACH OCCURRENCE $ 1,000,000 <br />DAMAGE TO RENTED s 50,000 <br />MED EXP (Any one mon S 5,000 <br />PERSONAL & ADV INJURY S 1,000,000 <br />GEN'L AGGREGATE LIMIT APP IES PER: <br />POLICY ❑ jE8T LOC <br />OTHER: <br />GENERAL AGGREGATE S 2,000,000 <br />PRODUCTS - COMP/OP AGG 1 S 2,000,000 <br />S <br />C <br />AUTOMOBILE LIABIIJTY <br />X ANY AUTO <br />OWNED SCHEDULED <br />AU70S ONLY AUTOS <br />AUTOS ONLY AUTO ONLY <br />BAW56383417 <br />02/2712017 <br />02/2712018 <br />COMBINED (Ea accidentlSINGLE LIMIT S 1,000,000 <br />BODILY INJURY (Per person) S <br />BODILYBODILY INJURY Per accident S <br />PROPERTY DAMAGE I s <br />Per accident <br />5 <br />UMBRELLA LIABOCCUR <br />EXCESS LIAB <br />HCLAIMS-MADE <br />EACH OCCURRENCE I S <br />AGGREGATE S <br />DED RETENTION $ <br />S <br />B <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETOWPARTNERIEXECUTIVE <br />DFFICERIMEMBER EXCLUDED? <br />(Mandatory in NH) <br />11 yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />NIA <br />921878217 <br />10/01/2017 <br />10/01120181,000,000 <br />1010`112018E <br />X PTRLITE OT-RH- <br />L. EACH ACCIDENT 5 <br />I 1,000,000 <br />E.L. DISEASE - EA EMPLOYEEI 5 <br />1,000,000 <br />E.L. DISEASE -POLICY LIMIT S <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) <br />Proof of coverage <br />CANCELLATION <br />CE RTIFICATE HOLDER <br />INTERNA <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Internal Use only <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />
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