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COMPLIANCE INFO_2023
Environmental Health - Public
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2300 - Underground Storage Tank Program
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PR0232355
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COMPLIANCE INFO_2023
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Entry Properties
Last modified
8/3/2023 11:09:42 AM
Creation date
5/17/2023 8:34:04 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2023
RECORD_ID
PR0232355
PE
2361
FACILITY_ID
FA0000591
FACILITY_NAME
QUIK STOP MARKET #551152
STREET_NUMBER
1721
Direction
S
STREET_NAME
CHEROKEE
STREET_TYPE
LN
City
LODI
Zip
95240
APN
062-060-48
CURRENT_STATUS
01
SITE_LOCATION
1721 S CHEROKEE LN #1
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> 03/03/2023 <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 CONTACT Shala Pearson <br /> NAME: <br /> TLB Insurance Services HONNo Ext): (916)790-5863 A No): (888)329-8842 <br /> CA License#01382095 E-MAIL shala-pearson@leavitt.com <br /> ADDRESS: <br /> 2358 Maritime Dr,Ste 100 INSURER(S)AFFORDING COVERAGE NAIC# <br /> Elk Grove CA 95758 INSURERA: Westchester Surplus Lines Insurance Company 10172 <br /> INSURED INSURER B: Travelers Property Casualty Company of America 25674 <br /> Walton Engineering,Inc. INSURERC: Service American Indemnity Company 39152 <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: 23/24 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 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 ADDLSUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS <br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> DAMAGCLAIMS-MADE FX OCCUR PREM SES Ea oNcErDence $ 50,000 <br /> X Inc.Pollution Liability MED EXP(Any one person) $ 5,000 <br /> A X Inc.Professional Liability G47393735001 03/06/2023 03/06/2024 PERSONAL&ADV INJURY $ 1,000,000 <br /> MOTHER <br /> LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 <br /> POLICY �JECT PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 <br /> PRO- <br /> : $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 <br /> Ea accident <br /> X ANY AUTO BODILY INJURY(Per person) $ <br /> B OWNED SCHEDULED 81081-785302 03/06/2023 03/06/2024 BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> X HIRED �/ NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY /� AUTOS ONLY Per accident <br /> Uninsured motorist $ 1,000,000 <br /> UMBRELLA LAB vZ"IZ6 V�WE'N— 10,000,000 <br /> OCCUR EACH OCCURRENCE $ <br /> A X EXCESS LIAB CLAIMS-MADE G47393747001 03/06/2023 03/06/2024 AGGREGATE $ 10,000,000 <br /> DED I X1 RETENTION $ O $ <br /> WORKERS COMPENSATION X PER STATUTE ER <br /> H <br /> AND EMPLOYERS'LIABILITY YIN 1,000,000 <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ <br /> C OFFICER/MEMBER EXCLUDED? NIA SAMTWC10020100 10/01/2022 10/01/2023 <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 <br /> If yes,describe under 1,000,000 <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> Inland Marine <br /> D Leased/Rented/Borrowed 6608K816207 03/06/2023 03/06/2024 Limit $300,000 <br /> Deductible $2,500 <br /> DESCRIPTION OF OPERATIONS/LOCATIONS I 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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