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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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DE VRIES
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2300 - Underground Storage Tank Program
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PR0231547
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COMPLIANCE INFO_2021
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Entry Properties
Last modified
12/28/2021 10:51:43 AM
Creation date
5/5/2021 2:29:51 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2021
RECORD_ID
PR0231547
PE
2361
FACILITY_ID
FA0003848
FACILITY_NAME
Verizon Business: KINGCA
STREET_NUMBER
13850
Direction
N
STREET_NAME
DE VRIES
STREET_TYPE
RD
City
LODI
Zip
95242
APN
05524018
CURRENT_STATUS
01
SITE_LOCATION
13850 N DE VRIES RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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�.-- � MJKCONS -01 DADACAYA <br /> ACORL7� CERTIFICATEOF LIABILITY INSURANCE DATE (MM/DD/YYYY) <br /> 1 ,x..4 11 /23/2020 <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 License # OE67768 CARE?cT Almie Dadacay <br /> IOA130 Insurance Services (AHlc°,No, Ext): (949 297-5530 52002 FAx <br /> 130 Vantis ) (A/C, No): (949) 297-5960 <br /> Suite 250 EODRIEs : aimie . dadacay@ioausa .com <br /> Aliso Viejo, CA 92656 <br /> INSURER(S) AFFORDING COVERAGE NAIC # <br /> INSURER A : Nautilus Insurance Company 17370 <br /> INSURED INSURER B : Key Risk Insurance Company 10885 . <br /> Sunwest Engineering Constructors, Inc. INSURER C : State Compensation Insurance Fund of CA 35076 <br /> 4780 Cheyenne Way INSURER D : Travelers Property Casualty Company of America 25674 <br /> Chino, CA 91710 <br /> INSURERE : <br /> INSURER F : <br /> COVERAGES 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 /> INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS <br /> LTRA X COMMERCIAL GENERAL LIABILITY EACH OCCU2occurrence) <br /> $DA 2,000,000 <br /> CLAIMS-MADE OCCUR X X ECP202766213 12/1 /2020 12/1 /2021 PREMIDAMASES TO <br /> 100,000 <br /> P E SES 5 <br /> MED EXP Arson $ 51000 <br /> PERSONAL & ADV INJURY $ 210009000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 41000' 000 <br /> POLICY ❑X JERCOT- F�] LOC PRODUCTS - COMP/OP AGG $ 41000, 000 <br /> OTHER: Deductible : $5, 000 PRODUCTS LIAB . $ Included <br /> B COMBINED SINGLE LIMIT 11000,000 <br /> AUTOMOBILE LIABILITY Ea accident $ <br /> X ANY AUTO BAP202766112 12/1 /2020 12/1 /2021 BODILY INJURY Perperson) $ <br /> OWNED SCHEDULED <br /> AUTOS ONLY AUTOS BODILY INJURY Per accident $ <br /> HIRED NON-0 ED PPe�acEcident AMAGE $ <br /> AUTOS ONLY AUTOS ONLY <br /> $ <br /> AUMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 6'000' 000 <br /> X EXCESS LIAB CLAIMS-MADE FFX202766312 12/1 /2020 12/1 /2021 AGGREGATE $ 610003000 <br /> DED X RETENTION $ 10,000 <br /> C WORKERS COMPENSATION X PTT UTE AND EMPLOYERS'EMPLOYERS' LIABILITY Y / N9243819-20 12/1 /2020 12/1 /2021 1 ,0001000 <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE X E.L. EACH ACCIDENT . $ <br /> OFFICER/MEMBER EXCLUDED? N / A <br /> 13000,000 <br /> (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $.._.-_ <br /> Ifyes, describe under 1 , 000 ,000 <br /> DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT $ <br /> A PL - Per Claim $1MIL ECP202766213 12/1 /2020 12/1 /2021 Per Aggregate 21000 ,000 <br /> D Leased/Rented - RC 630311122616 12/1 /2020 12/1 /2021 Deductible : $1 ,000 2509000 <br /> DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101 , Additional Remarks Schedule, may be attached If more space Is required) <br /> Contractors Pollution <br /> Carrier: Nautilus - Policy #ECP202766213 <br /> Effective: 12/01 /2020 to 12/01 /2021 <br /> Aggregate : $4MIL - Each Claim : $2MIL - Ded : $5,000 <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 /> ACCORDANCE WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> / v <br /> ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION . All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br /> i <br /> r <br />
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