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SR0084686 (2)
Environmental Health - Public
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2900 - Site Mitigation Program
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SR0084686 (2)
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Entry Properties
Last modified
10/31/2022 2:50:04 PM
Creation date
10/31/2022 2:39:36 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
WORK PLANS
RECORD_ID
SR0084686
PE
2903
FACILITY_ID
FA0026932
FACILITY_NAME
TRACY HILLS WATER TANK
STREET_NUMBER
5403
STREET_NAME
TRACY HILLS
STREET_TYPE
DR
City
TRACY
Zip
95377
APN
25105031
ENTERED_DATE
1/4/2022 12:00:00 AM
SITE_LOCATION
5403 TRACY HILLS DR
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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RO® CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDIYYYY) <br />-�1 1 12/14/2021 <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(ies) 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 <br />HUB International Insurance Services Inc. <br />PO Box 255387 <br />Sacramento CA 95865 <br />INSURED <br />Fox Loomis Inc. <br />6901 Mc Comber Street <br />Sacramento CA 95828 <br />COVERAGES <br />CERTIFICATE NUMBER:1s7sna15a2 <br />nternational.com <br />INSURER e : Vallev Foroe Insurance <br />nental Insurance <br />D: Oak River Insurance Co <br />RFVIRIC]N NIIMRFR• <br />916-993-7253 <br />20443 <br />20508 <br />34630 <br />THIS 15 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 />ILTR <br />TYPE OF INSURANCE <br />INSDL <br />SUER <br />POLICY NUMBER <br />MMIDDYN <br />MMIDDIYYYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE %( OCCUR <br />Y <br />Y <br />4016689746 <br />10/1/2021 <br />10/1/2022 <br />EACH OCCURRENCE <br />$10000,000 <br />DE TO RENTED <br />PREMISES Ea occurrence <br />$ 100,000 <br />MED EXP (Any one person) <br />$ 15,000 <br />PERSONAL &ADV INJURY <br />$10000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY M JECT LOC <br />OTHER: <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />PRODUCTS • COMP/OP AGG <br />$ 2,000,000 <br />$ <br />B <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRED X NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />Y <br />Y <br />4016869777 <br />10/1/2021 <br />10/1/2022 <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$1 ,000,000 <br />X <br />BODILY INJURY (Per person) <br />$ <br />BODILY INJURY Per accident <br />( ) <br />$ <br />X <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />C <br />X <br />UMBRELLA LIAB <br />EXCESS LIAB <br />X <br />OCCUR <br />CLAIMS -MADE <br />4016889763 <br />10/1/2021 <br />10/1/2022 <br />EACH OCCURRENCE <br />$ 5,000,000 <br />AGGREGATE <br />$ 5,000,000 <br />DED <br />I X <br />I RETENTION $ 1 n rinn <br />$ <br />D <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y I N <br />ANYPROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBEREXCLUDED? <br />(Mandatory In NH) <br />If as, describe under <br />DESCRIPTION OF OPERATIONS below <br />NIA <br />Y <br />I <br />FOWC217595 <br />I <br />10/1/2021 <br />10/1/2022 <br />X <br />STATUTE <br />ETH <br />E.L. EACH ACCIDENT <br />$ 1,000,000 <br />E,L. DISEASE- EA EMPLOYEE <br />$1,000,000 <br />E.L. DISEASE - POLICY LIMIT <br />$1,000,000 <br />A <br />Limited Pollution Liability <br />4016689746 <br />10/1/2021 <br />10/1/2022 <br />Each Incident <br />Aggregate Limit <br />$1,000,000 <br />$2,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) <br />(Per Project Aggregate applies when required by written contract.) <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 />AUTHORIZ/ED�REPRESENTATIVE <br />©1988.2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD <br />
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