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0 <br />q�Q SERVSTA-01 i <br />LICHI <br />�... ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYM <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDR'THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, E---------------- <br />XTEND 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 h: an ADDITIONAL INSURED, the policy <br />must be endorsed. N SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain Policies may require an endorsement. A statement on this certificate does not confer rights to the <br />cortIlIcate holder in lieu of such endomement(s). <br />PRODUCER License # 0603247 <br />George Petersen Insurance Agency, Inc. NAME: <br />P.O. Box 3539 P" (80 <br />.r, <br />0 236.9046 <br />Santa Rosa, CA 95402 A/C No): (888) 579.2743 <br />INSURED <br />Service Station Systems, Inc. <br />680 Quinn Ave <br />San Jose, CA 95112 <br />ICW <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT pR 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 />R TYPE OF INSURANCE POLICY NUMBER <br />GENERAL LIABILITY SER MIDDIY YY LIMITS <br />COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br />CLAIMS -MADE F—I OCCUR PREMISES Ea occurrence $ <br />MED EXP (Any one Dersonl S <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />AUTOMOBILE LIABILITY <br />ANY AUTO <br />IAUTALLOS n <br />SCHEDULED <br />CJI <br />AUTOS <br />HIRED AUTOS 11} <br />OWNED <br />UMBRELLA LIABOCCUR <br />EXCESS LIAR .,.... <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />A ANY PROPRIETOR/PARTNERIEXECUTNEY/N <br />OFFICER/MEMSER EXCLUDED? F N / A <br />In NMI <br />AGG <br />BODILY INJURY (Per person) $ <br />BODILY INJURY (Per accident) $ <br />(lPReraodde tDAMAGE $ <br />AGGREGATE <br />6/4/2012 6/4/'2013 E.L. EACH ACCIDENT $ 1 <br />E.L. DISEASE - EA EMPLOYE $ 1 <br />E.L DISEASE -POLICY LIMIT $ 1 <br />DESCRIPTION OF OPERATIONS / LOCA710NS / YEHK LES (Attach ACORD 101, AddtUonal Remarks Sehedul®, M more apace Is reqrod) <br />'roof of coverage ui <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 />ACORD 25 (2010f05)The ACORD name and logo are registered marks of ACORD ®CORPORATION. All rights reserved. <br />