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COMPLIANCE INFO_2016
Environmental Health - Public
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EHD Program Facility Records by Street Name
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JACK TONE
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2300 - Underground Storage Tank Program
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PR0505264
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COMPLIANCE INFO_2016
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Last modified
8/11/2021 10:45:06 AM
Creation date
6/23/2020 6:57:24 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2016
RECORD_ID
PR0505264
PE
2361
FACILITY_ID
FA0006672
FACILITY_NAME
FLYING J TRAVEL PLAZA #618*
STREET_NUMBER
1501
Direction
N
STREET_NAME
JACK TONE
STREET_TYPE
RD
City
RIPON
Zip
95366
APN
22811017
CURRENT_STATUS
01
SITE_LOCATION
1501 N JACK TONE RD
P_LOCATION
05
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\UST\UST_2361_PR0505264_1501 N JACK TONE_2016.tif
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EHD - Public
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JONECOV-02 DADACAYA <br />lhl O ® CERTIFICATE OF LIABILITY INSURANCE °A.TE <br />l2-e/l°°1A i <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 INSURER($), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: It the certl0cate holder Is an ADDITIONAL INSURED, the polioy(ies) must be endorsed. If 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 />certificate holder In lieu of such endorsement(s). <br />PRODUCER Manse # OE67768 <br />JOA Insurance Services <br />130 Yantis <br />C AC <br />NAME: <br />PHONE FAX <br />,1949)297-5962 N.1. (949)297-5960.. <br />Suite 250 <br />Aliso Viejo, CA 92658 <br />ADDRESS: <br />INSURER_IS)AFFOROINGCOVERAGE NAICIf <br />InsuranceComn 39993 <br />INSURED <br />INSURER B: Philadel hia Indemnity Insurance Company_. 18051) <br />Jones Covey Group, Inc. <br />INSURERc: Everest National Insurance Company 10120 <br />INSURERD: <br />9595 Lucas Ranch Rd Ste 100 <br />Rancho Cucamonga, CA 91730 <br />INSURER E: <br />INSURER F: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 />INSR ryPE OFINSUIIANCE AOOCiSDBR PODCY NUMBER MOLICYEFF P6L UMRS <br />A <br />WeIDTYEACH <br />AUTT�"MDnREP�pJRESENTTA/TVE <br />C / C <br />OCCURRENCE S 5,000,00 <br />CLAIMS -MAGE ❑X DOWN <br />ACE301425 <br />07!0112018 <br />07/0112017 <br />PREMISES a $ 300,000 <br />MEDEXP(Anrwmpmson) S 25,00 <br />TCOMMERCIALGENERAL <br />FERSONALSADVINJURY $ 5,000,00 <br />GENT AGGREGATE LIMIT APPLIES PER: <br />GENERALAGGREGATE S 5,000,60 <br />POLICY [X] PRO O LOC <br />PRODUCTS -COMPA)P AGG $ <br />_5,0_00,00 <br />S <br />OTHER: <br />AUTOMOBILE LIABILRY <br />B'�NEEDDSINGLELIMIT $ 1,000,00 <br />B- <br />ANr AUTO <br />PHPKIS14144 <br />0710112016 <br />07/01/2017 <br />......-__ .._.-.._..__-_ <br />BODILY INJURY (Per Person) S <br />ALLOS <br />AU % SCHEDULED <br />_ AIiT� <br />BODILY INJURY IPereaNeM) _5 <br />X HIREDAUTOS NMIIXTdWNED <br />X <br />Pae repAMAGE S <br />S <br />UMBRELLALIAA X <br />OCCUR �-_-_ <br />-- <br />_ <br />EACH OCCLRiRENCE 5 2,000,00 <br />A <br />X EXCESS UAB <br />CLAIM.WDE <br />EXC305426 <br />0710112016 <br />0710112017 <br />AG!8 2,000,00 <br />GREGnrE <br />DED X I RETENTION$ <br />0 <br />S <br />WORKERS COMPENSA71ON <br />X PER OTH- <br />STATUTE ER <br />ANDEMPLOYERS'UAMILnY YIN <br />_ <br />EJ.. EACH ACCIDENT $ 1,000.000 <br />C <br />ANY PROPRIE—ARTNERIF.%F—W <br />OFFlCERIMEMBEft E%CLUDEDT YO <br />(MyaanUMory in NH) <br />NIA A <br />CA10002046161 <br />05101/2016 <br />0510112017 <br />E).. DISFgSF.FA F.MPLOYF. $ 11000,00 <br />OE6CRIPTIONOfOPERATXNJS below <br />EL DISEASE-POLX;Y UNIT I S 1,000,00 <br />A <br />Llab. <br />PACE305425 <br />07/0112016 <br />07)0112017 <br />5,000,00 <br />A <br />�Professlonal <br />Contractors Poli. <br />PACE305425 <br />0710112016 <br />0710112017 <br />5,000,00 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD let, Aft—RA— S—d-, mry lb——d If more apace N mq—d) <br />Proof of Coverage. <br />Uc TBBtl- —A KU uunrVKAi-N. All nonts reseTeo. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />a* <br />C <br />v <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTT�"MDnREP�pJRESENTTA/TVE <br />C / C <br />Uc TBBtl- —A KU uunrVKAi-N. All nonts reseTeo. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />a* <br />C <br />v <br />
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