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COMPLIANCE INFO_2005 - 2009
Environmental Health - Public
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2300 - Underground Storage Tank Program
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PR0231433
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COMPLIANCE INFO_2005 - 2009
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Last modified
2/19/2020 4:59:42 PM
Creation date
2/19/2020 10:50:10 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2005 - 2009
RECORD_ID
PR0231433
PE
2361
FACILITY_ID
FA0003685
FACILITY_NAME
DBA CIRCLEK, REFUEL PETROLEUM INC.
STREET_NUMBER
419
Direction
S
STREET_NAME
MAIN
STREET_TYPE
ST
City
MANTECA
Zip
95336
APN
21938610
CURRENT_STATUS
01
SITE_LOCATION
419 S MAIN ST
P_LOCATION
04
P_DISTRICT
005
QC Status
Approved
Scanner
KBlackwell
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EHD - Public
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POLICYHOLDER -`PY NJ <br /> STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> COMPENSATION <br /> INSURANCE <br /> FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> ISSUE DATE: 10-01-2008 GROUP: 000713 <br /> POLICY NUMBER: 0007639-2008 <br /> CERTIFICATE ID: 2 <br /> CERTIFICATE EXPIRES: 10-01-2009 <br /> 10-01-2008/10-01-2009 <br /> CONTRACTORS STATE LICENSE BOARD NJ LICENSE NUMBER:#768938 <br /> WORKERS COMP UNIT INCEPTION DATE:10-01-2008 <br /> P 0 BOX 26000 DO:NJ <br /> SACRAMENTO CA 95826 <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 belovv 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 /> tTH ( J <br /> ORIZED REPRESENTATI PRESIDENT <br /> EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> ENDORSEMENT #1600 - VENDEIRO, MARK, P - EXCLUDED. <br /> ENDORSEMENT #1600 - VENDEIRO, LAURA CHRISTINE, S,T - EXCLUDED. <br /> ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2005 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> EMPLOYER <br /> MVP PETROLEUM ENGINEERING INC DBA:MVP NJ <br /> PETROLEUM ENGINEERING INC <br /> PO BOX 281 <br /> FOLSOM CA 95763 <br /> M0409 <br /> (RE V.2-05) <br /> PRINTED : 09-17-2008 <br />
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