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SERVSTA-01 ILICHA <br />CERTIFICATE F LIABILITY DATE(MM/DD/YYYY) <br />I INSURANCE s/sno12 <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 INSUR D BY AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER License IF 0603247 COW <br />T <br />George Petersen Insurance Agency, Inc. NAME <br />P.O. Box 3539 arC . (800) 236-9046 A� No , (888! 579-2743 <br />Santa Rosa, CA 95402 _+Aa.__ <br />INSURED <br />Service Station Systems, Inc. <br />680 Quinn Ave <br />San Jose, CA 95112 <br />101TA <br />11 <br />vvCKAUM0 CERTIFICATE NUMBER: 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 />M <br />TYPE OF INSURANCE a -on <br />LTR INSR Wve POLICY NUMBER (MMILDD/YYYYI tMM�D) LIMITS <br />GENERAL LIABILITY i <br />EACH <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR PREM <br />DT <br />PER Si <br />GENT AGGREGATE LIMIT APPLIES PER: <br />7 POLICY PRO- D LOC <br />AUTOMOBILE LIABILITY <br />ANY AUTO <br />ALL AUTOS AUULED <br />UTTOS <br />HIRED AUTOS NON -OWNED <br />AUTOS <br />UMBRELLA LIARI I OCCUR <br />EXCESS LIAR ff---i' r, ewc <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />A ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N <br />OFFICER/MEMBER EXCLUDED? INIA <br />(Mandatory In NH) <br />If yes, describe under <br />6/4/2012 1 6/4/2013 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) <br />goof of coverage <br />any one <br />& ADV <br />0 <br />BODILY INJURY (Per person) $ <br />BODILY INJURY (Per accident) $ <br />PROPERTY DAMAGE $ <br />PeracadenI <br />EACH OCCURRFNCF c <br />E.L. EACH ACCIDENT I $ 1,000,00 <br />E.L. DISEASE - EA EMPLOYEd S 1.000.000 <br />LIMIT <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Proof of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />01- <br />0 1988-2010 <br />ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD <br />