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COMPLIANCE INFO_2021
Environmental Health - Public
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EHD Program Facility Records by Street Name
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HAMMER
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2300 - Underground Storage Tank Program
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PR0231130
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COMPLIANCE INFO_2021
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Entry Properties
Last modified
12/1/2021 4:41:38 PM
Creation date
4/5/2021 1:45:41 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2021
RECORD_ID
PR0231130
PE
2361
FACILITY_ID
FA0002232
FACILITY_NAME
QUIK STOP MARKET #132
STREET_NUMBER
3555
Direction
W
STREET_NAME
HAMMER
STREET_TYPE
LN
City
STOCKTON
Zip
95219
APN
071-180-20
CURRENT_STATUS
01
SITE_LOCATION
3555 W HAMMER LN
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
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EHD - Public
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Aco® CERTIFICATE OF LIABILITY INSURANCE DATE (MMDD/YYYY) <br /> 03/04/2021 <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(S), AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT Shale Pearson <br /> NAME: <br /> TLB Insurance Services PHONE (916) 790-5863 FAX (888) 329-8842 <br /> A/C No Extl: AIC No): <br /> CA License #OB82095 E-MAIL shala-pearson@leavitt.com <br /> ADDRESS: <br /> 2358 Maritime Dr, Ste 100 <br /> INSURER(S) AFFORDING COVERAGE NAIC # <br /> Elk Grove CA 95758 INSURERA : Admiral Insurance Company 24856 <br /> INSURED INSURER B : Travelers Property Casualty Company of America 25674 <br /> Walton Engineering , Inc. INSURER C : State Compensation Insurance Fund 35076 <br /> P. O. Box 1025 INSURER D : Travelers Property Casualty Company, 36161 <br /> INSURER E : <br /> West Sacramento CA 95691 INSURER F : <br /> COVERAGES CERTIFICATE NUMBER: 21 /22 Master 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAYBE 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 /> IFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DDIYYYY MMDD/YYYY LIMITS <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 110001000 <br /> CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 50,000 <br /> PREMISES Ea occurrence) $ <br /> X Inc. Pollution Liability MED EXP Any oneperson) g 51000 <br /> A X Inc. Professional Liability FEIECC1358708 03/06/2021 03/06/2022 PERSONAL & ADV INJURY $ 1 , 000, 000 <br /> GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2, 0001000 <br /> POLICY PRIft 2, 000,000 <br /> JECT LOC PRODUCTS - COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 , 000, 000 <br /> Ea accident <br /> X ANYAUTO BODILY INJURY (Per person) $ <br /> B OWNED SCHEDULED 8108L785302 03/06/2021 03/06/2022 BODILY INJURY (Per accident) $ <br /> AUTOS ONLY AUTOS <br /> X HIRED NON-OWNED PROPERTY DAMAGE <br /> AUTOS ONLY X AUTOS ONLY Per accident $ <br /> Uninsured motorist $ 11000, 000 <br /> UMBRELLA LIAR ��„ �w�, .�� '"�� �w'�" "" " % 10,000, 000 <br /> Me <br /> OCCUR EACH OCCURRENCE $ <br /> A X EXCESS LIAB LAIMS•MADE FEIEXS1358808 03/06/2021 03/06/2022 AGGREGATE $ 10, 000, 000 <br /> DED X RETENTION $ 0 $ <br /> WORKERS COMPENSATION X STATUTE ETH <br /> AND EMPLOYERS' LIABILITY <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E. L. EACH ACCIDENT $ 12000,000 <br /> C OFFICER/MEMBEREXCLUDED? N / A 9113339 10/01 /2020 10/01 /2021 <br /> (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1 ,000, 000 <br /> I/ yes, describe under 1 ,000, 000 <br /> DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ <br /> Inland Marine <br /> D Leased/Rented/Borrowed 66081<816207 03/06/2021 03/06/2022 Limit $300, 000 <br /> Deductible $2, 500 <br /> DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached if more space is required) <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> To Whom it May Concern Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS . <br /> AUTHORIZED REPRESENTATIVE <br /> © 1988-2015 ACORD CORPORATION. All rights reserved . <br /> ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />
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