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08/20/2004 16:13 2099480755 UALLEY PACIFIC PAGE 05 <br /> 08/10/2004 15:14 \,. 1.111r NO.620 0002 <br /> POLICYHOLDER COPY <br /> STATE P.O. BOX 420807,SAN FRANCISCO, CA 94142-0807 <br /> COMPeNSn1,01,1 <br /> INSUna NCE <br /> FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> ISSUE DATF, 06-10-2004 GROUP: 000713 <br /> POLICY NUMBER- 9433-2003 <br /> CERTIFICATE ID: so <br /> CERTIFICATE&XPIRES: io-01-2o04 <br /> 10-01-2001/l0-01-2004 <br /> VALLEY PACIFIC PETROLEUM <br /> 266 FRANK WEST CIRCLE <br /> STOCKTON CA 95206 <br /> This is to certify that we have issued a valid Workers Compensation insurance policy in a form approved by the California <br /> Insurance Commissioner to the employer named belew for the policy period indicated. <br /> This policy is not subject t0 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 covorage afforded by the <br /> policies listed herein.Notwmtatanding any requirement,term or condition of any contract or other document with <br /> respect to wnich this certificate of insurance may be issued of may pertain,the insurance afforded by the policies <br /> described herein is subject to all the terms,exclusions,and Conditions,of such policies. <br /> MITInp�ar�11f6FNTn'rNO PReMOTT <br /> BMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> ENDORSEMENT 01600 - NANCY L. JQMSON, PRP,S. - EXCLUDED. <br /> ENDORSEMENT #1600 - SCOTT D. J=SCN, SEC. - EXCLUDED. <br /> ENDORSEMENT #1600 DONNA L_ JOHNSON, V_D. - EXCLUDED. <br /> INDORSEMEUT #1600 - JULIAN D. JOHNSON, TRES. • EXCLUDED. i <br /> ENDORSEMENT 42065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-1996 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> EMKOYGe <br /> JOHNSON LIETROLBUN CONS7.RUCTION, INC. <br /> FO BOX 7169 <br /> AUDUAN CA 95604 <br /> SOF 1o217E WWI <br /> M'wptm�acvM.fRim o+gMyaumgaSint vammmhi�glnad�roFllcuL Srg1E FLNOencuNENi' �a°'"`b/AGE , pFt <br />