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SU0012412
Environmental Health - Public
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PA-1900153
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SU0012412
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Entry Properties
Last modified
5/7/2020 11:35:45 AM
Creation date
9/6/2019 10:41:51 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0012412
PE
2622
FACILITY_NAME
PA-1900153
STREET_NUMBER
31600
Direction
S
STREET_NAME
KOSTER
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
25515028
ENTERED_DATE
7/10/2019 12:00:00 AM
SITE_LOCATION
31600 S KOSTER RD
RECEIVED_DATE
7/12/2019 12:00:00 AM
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
Scanner
TSok
Supplemental fields
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\MIGRATIONS\K\KOSTER\31600\PA-1900153\SU0012412\APPL.PDF
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EHD - Public
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'. MELOMAC-01 IBLU <br /> ACORD, CERTIFICATE OF LIABILITY INSURANCE °10r�oo9 <br /> PRODUCER (209)578-0183 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION <br /> DlBuduo&DeFendis Insurance Agency,Inc.-Modesto ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR <br /> License 110707137 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br /> P.O.Box 580531 <br /> Modesto,CA 95358-0071 INSURERS AFFORDING COVERAGE MAIC 8 <br /> INSURED - Jim N.Melo S Brenda Melo dba:Melo Machine& MSI.RERJL Everest National Insurance Company <br /> Manufacturing NStRER R _... <br /> P O Box 517 INSURER C. <br /> Patterson,CA 95363-0000 RSR D- <br /> INSURER E: <br /> COVERAGES <br /> THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING <br /> ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br /> MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH <br /> POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- <br /> IL <br /> �� POUCYUTEk V7 POLICY E1tPRATION - LaCTS -- <br /> LTR I=OF NVURQCE <br /> DATE 044MA1011 DATE MRVDDnM <br /> GENERAL LWBA1rY EACH OCCiJf32QVC£ f <br /> COWERCIAL GENERAL LIABILITY PREMISES Ea ocarvice f <br /> CL11M5 MADE U 00cUR We are required tyy our E&O Carrier t0 forw ird a copy of WED FP(Any we persml <br /> -•� . --.-_ �- ,mss-. - -,,�.,_each-certificate ofinsuranc(-issued to your office for- -P6'�s�c�`Abv l4juv- s l <br /> ur records. Please do nol return. G-94ERALAGGREGAT s <br /> GENL Af GfEG4TE LIMIT APPLIES PER PRODUCES-COW10P AiGG a <br /> POLICY D <br /> PRO- LOC <br /> AUTOMOBILE LIABILITY CO BRED 544GLF LIMIT a <br /> ANY AlJTO (Ea aCdd it) <br /> -- ALL OYNdEU AUTOS BODILY INJJRY = <br /> SChEIYAE D ADIOS ;Per person) <br /> - I <br /> HIRED AUTOS BODILY IN.IURY f <br /> NOW0VW ED ALTTOS (Per ea3dero <br /> PROPERTY DAMAL,E f <br /> {Por acciderYl <br /> GARAGE LIASiLITY AUTO ONLY-EA ACCIDENT f <br /> _ ANY AUTO OTFER THAN FA AGC f <br /> ALITO ONLY: AC* a <br /> E(CESSA UBREL LA UABLT Y FA-1H OC .IRRENCE -- <br /> OGGLR FIC1ADAS MADE AUGREGATE S -- <br /> f <br /> IDEDLIC71BLE f <br /> RETENT" f f <br /> WOfi�RS COMPENSATION AND X kY IM TS OER _ <br /> A IE3IPLOYERT LIABILITY A20010249081 31112008 31112008 E.I.EACH ACCIDENT f 1,000,00 <br /> ANY PROPRIETORIPARTNERIEXECITNE 1 ON,OfFFFFICIRI E7+BER E XCLLDED? E.L.DISEASE-EA EMPLOYEE i <br /> SPECIAL maunder blow El.DISEASE-POLICY LMT $ -- -1,000,00f <br /> OTHER <br /> DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS <br /> 0 day notice of cancellation due to non payment of premium applies. <br /> Re:Install new pump In well as 31600 Koster Rd.Tracy,CA on 01/09108 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br /> Nat Bachetti DATE m*REOF,THE mum RAS jRER VYLL BSIEAvoRTD w& 30 DAYS VWRrrnN <br /> 31600 Koster Rd <br /> Tracy,CA 95304- NOTICE To THE CSTTFICATE IIOLDSR ru11ED TO THE LEFT,BUT FAILURE TO DO so WALL <br /> NOSE NO OBLIGATION OR LIABLTTY OF ANY KIND LIPON THE H8URER,ITS AGILE 5 OR <br /> REPRESENTATIVES. <br /> AUTHORS RErRESENTATNE <br /> ACORD 26(2001108) ����� � 9ACORD CORPORATION 1988 <br />
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