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Home My WebLink About1520 20TH STREET (15)4 State of California State of Water Resources Control Board For Siate Use Only Division of Financial Assistance b P.O. Boa 944212 Sacramento, CA 94244 -21204pyiFON, Instructi ons on reverse side) FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am required to demonstrate Financial Responsibility in the required amounts as specified in Section 2807, Chapter 18, Div. 3. Tide 23, CCR: X00,000 dollus per occw rence 1 ntillion dollars annual aggregate of AND or I ntillion dollars per occurrence FR-12 million dollars annual aggregate B. Pacific Bell Telephone Co, dba AT &T California hereby certifies that it is in compliance with the requirements of Name of Tank Owneror Operator) California Code of Regulations, Title 23, Division 3, Chapter 18, Article 3, Section 2807. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party Type Name and Address of Issuer Number Amount Period Action Comp Certificate of Insurance Old Republic MWZZ50593 1,000,000 per 06/01/2012 - YES YES Insurance Company occurrence and 06/01/2015 414 W. Pittsburgh St. 2,000,000 Greensburg, PA 15601 annual aggregate Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies that you are in compliance and shall maintain compliance with all conditions for participation in the Fund. See instructions. D. Facility Name Facility Address See Attached Facility Name Facility Address Facility Name Facility Address E. Si nature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator 5 /23/12 kl Art Kirchoffer — Assistant Treasurer nature of Witnes's or Notafj %' Date Name of Witness or Notary J 5 /23/12 Edna Gilchrist f; CFR (Revised 08/06) FILE: Original - Local Agency Copies - Facility /Site(s) Active—UST—list—for—FA-1 20214 Page 1 aW May 21, 2012 Bakersfield City Fire Department UST Compliance 2101 H Street Bakersfield, CA 93301 AT &T EH &S T: 214.464.3131 308 S. Akard Street #1700 F: 214.464.1424 Dallas, TX 75202 www.ehs.att.com RE: Certification of Financial responsibility - Underground Storage Tanks To whom it may concern, Enclosed please find a copy of our annual State of California Certification of financial responsibility and a Certificate of insurance to demonstrate the financial responsibility of Pacific Bell Telephone Company /dba AT &T California, AT &T Corp and /or its affiliate company for its underground storage tanks. Also enclosed please find a list of the sites that are covered by insurance and that have underground storage tanks on the premises in your area of jurisdiction. If you have any questions or require any additional information, please feel free to contact me at (214) 464.3131 or by email at sh19750att.com. Thank you for your help complying with this requirement. Sincerely, Steven 3 Hall Manager, Environment, Health & Safety AT &T Services Inc. Attachment: Certification of Financial Responsibility List of insured sites with underground storage tanks Certificate of insurance IJAME: ADDRESS: POLICY NUMBER: ENDORSEMENT: PERIOD OF COVERAGE: NAME OF INSURER: ADDRESS OF INSURER: NAME OF INSURED: ADDRESS OF INSURED CERTIFICATE OF INSURANCE Per the Attached List Per the Attached List MWZZ50593 Not applicable June 1, 2012 — June 1. 2015 Old Republic Insurance Company 445 South Moorland Road Brookfield. WI 53005 Subsidiaries and Affiliates of AT&T Inc. 208 S. Akard Street Room 2731 Dallas, Texas 75202 CERTIFICATION: 1. Old Republic Insurance Company, the Insurer, as identified above; hereby certifies that it has issued Liability insurance covering the following underground storage tank(s): See Schedule of Tanks on policy referenced above, for taking corrective action and con-,pensatins third parties for bodily injury and property damage caused by accidental releases in accordance with and subject to the limits of liability, exclusions, conditions and other terms of the policy arising from operating the underground storage tank(s) identified above, The limits of liability are $1,000,000 each occurrence and $2,000,000 annual aggregate, exclusive of legal defense costs.. which are subject to a separate limit under the policy. This coverage is provided under poticv number MWZZ5059:3. The effective date of said policy is June 1, 2012. 2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1: a. Bankruptcy or insolvency of the insured shalt not relieve the Insurer of its obligations under the policy to which this certificate applies. b. The Insurer is liable for the payment of amounts within any deductible applicable to the policy to the provider of corrective action or damaged third party, with a right of reimbursement by the insured for any such payment made by the Insurer. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in 40 CFR 280.95 - 280.102. c. Whenever requested by a Director of an implementing agency, the Insurer agrees to furnish to the Director a signed duplicate original of the policy and all endorsements. d. Cancellation or any other termination of the insurance by the Insurer, except for non- payment of premium or misrepresentation by the insured, will be effective only upon written notice and only after the expiration of 60 days after a copy of such written notice is received by the insured. Cancellation for non- payment of premium or misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum of 10 days after a copy of such written notice is received by the insured. e. The insurance covers claims otherwise covered by the policy that are reported to the Insurer within six months of the effective date of cancellation or non- renewal of the policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or termination date. Claims reported during such extended reporting period are subject to the terns, conditions, limits, including limits of liability, and exclusions of the Policy. I hereby certify that the wording of this instrument is identical to the wording in 40 CFR 280.97 b)(2) and that the Insurer is licensed to transact the business of insurance in one or more states. I Signature of Authorized Representative of Insurer Jodi Hartmann Senior Account Manager Old Republic Insurance Company 445 South Moorland Road Brookfield, WI 53005 02567 State ofCalifornia J'p8, State of Water Resources Control Board For State Use Only Division of Financial Assistance P.O. Box 944212 Sacramento, CA 94244 -2120 Instructions on reverse side) CERTIFICATI ®N OF FINANCIAL RESPONSIBILITY FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. 1 am required to demonstrate Financial Responsibility in the required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: 500,000 dollars per occurrence R I million dollars annual aggregate or AND or X 1 mullion dollars per occurrence ®2 million dollars annual aggregate B. AT &T CORP. hereby certifies that it is in compliance with the requirements of Name of Tank Owner or Operator) California Code of Regulations, Title 23, Division 3, Chapter 18, Article 3, Section 2807. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party Type Name and Address of Issuer Number Amount Period Action Comp Certificate of Insurance Old Republic MWZZ50593 1,000,000 per 06/01/2012 - YES YES Insurance Company occurrence and 06/01/2015 414 W. Pittsburgh St. 2,000,000 Greensburg, PA 15601 annual aggregate Note: Ifyou are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies thatyou are in compliance and shall maintain compliance with all conditions for participation in the Fund. See instructions. D. Facility Name Facility Address See Attached Facility Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator,, Date Name and Title of Tank Owner or Operator fl 5 /23/12 Art Kirchoffer — Assistant Treasurer Signature of Witness or Notary, Date Name of Witness or Notary 23/12 Edna Gilchrist5 CPR (Revised 08/06) FILE: Original - Local Agency Copies - Facility /Site(s) Active—UST—list—for—FA-1 20214 Page 1 at &t May 21, 2012 Bakersfield City Fire Department UST Compliance 2101 H Street Bakersfield, CA 93301 AT &T EH &S T: 214.464.3131 308 S. Akard Street #1700 F: 214.464.1424 Dallas, TX 75202 www.ehs.att.com RE: Certification of Financial responsibility - Underground Storage Tanks To whom it may concern, Enclosed please find a copy of our annual State of California Certification of financial responsibility and a Certificate of insurance to demonstrate the financial responsibility of Pacific Bell Telephone Company /dba AT &T California, AT &T Corp and /or its affiliate company for its underground storage tanks. Also enclosed please find a list of the sites that are covered by insurance and that have underground storage tanks on the premises in your area of jurisdiction. If you have any questions or require any additional information, please feel free to contact me at (214) 464.3131 or by email at sh1975C@att.com. Thank you for your help complying with this requirement. Sincerely, Steven 3 Hall Manager, Environment, Health & Safety AT &T Services Inc. Attachment: Certification of Financial Responsibility List of insured sites with underground storage tanks Certificate of insurance 14AME: ADDRESS: POLICY NUMBER ENDORSEMENT: PERIOD OF COVERAGE NAME OF INSURER: ADDRESS OF INSURER: NAME OF INSURED: ADDRESS OF INSURED: CERTIFICATE OF INSURANCE Per the Attached List Per the Attached List MWZZ50593 Not applicable June -1, 2012 — June 1. 2015 Old Republic Insurance Company 445 South Moorland Road Brookfield. WI 53005 Subsidiaries and Affiliates of AT&T Inc. 208 S. Akard Street Room 2731 Dallas. Texas 75202 CERTIFICATION: 1. Old Republic Insurance Company, the Insurer, as identified above, hereby certifies that it has issued liability insurance covering the following underground storage tank(s): See Schedule of Tanks on policy referenced above, for taking corrective action and compensating third parties for bodily injury and property damage caused by accidental releases in accordance with and subject to the limits of liability, exclusions. conditions and other terms of the policy arising from operating the underground storage tank(s) identified above, The limits of liability are $1,000,000 each occurrence and $2,000,000 annual aggregate, exclusive of legal defense costs; which are subject to a separate limit under the policy. This coverage is provided under policy number MWZZ50593. The effective date of said policy is June 1. 2012. 2, The Insurer further certifies the following with respect to the insurance described in Paragraph : a. Bankruptcy or insolvency of the insured shall not relieve the insurer of its obligations under the policy to which this certificate applies. b, The Insurer is liable for the payment of amounts within any deductible applicable to the policy to the provider of corrective action or damaged third party, with a right of reimbursement by the insured for any such payment made by the Insurer. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in 40 CFR 280.95 - 280.102. c. Whenever requested by a Director of an implementing agency, the Insurer agrees to furnish to the Director a signed duplicate original of the policy and all endorsements. d. Cancellation or any other termination of the insurance by the Insurer, except for non- payment of premium or misrepresentation by the insured, will be effective only upon written notice and only after the expiration of 60 days after a copy of such written notice is received by the insured. Cancellation for non- payment of premium or misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum of 10 days after a copy of such written notice is received by the insured. e. The insurance covers claims otherwise covered by the policy that are reported to the Insurer within six rnonths of the effective date of cancellation or non- renewal of the policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or termination date, Claims reported during such extended reporting period are subject to the terms, conditions, limits, including limits of liability, and exclusions of the policy. I hereby certify that the wording of this instrument is identical to the wording in 40 CFR 280.97 b)(2) and that the insurer is licensed to transact the business of insurance in one or more states. Signature of Authorized Representative of Insurer Jodi Hartmann Senior Account Manager Old Republic Insurance Company 445 South Moorland Road Brookfield, WI 53005 C12567 State of California For Slate Use Only State of Water Resources Control Board e Division of Financial Assistance 9,y P.O. Box 944.212 e; Sacramento, CA 94244 -2120v41, o (Insu'uctions on ievcrsc side) FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM A. I am requn-ed to demonstrate Financial Responsibility in the required amounts as specified in Section 2807, Chapter 18, Div. 3, Title 23, CCR: F] 500,000 doll-us per occurrence I nullion dollars annual aggregate or AND or Fx1 I nullion dollars per occurrence 2 nullion dollars annual aggregate B. Pacific Bell Telephone Co. dba AT &T California hereby certifies that it is in compliance with the requirements of Name of Tank Owner or Operator) California Code of Regulations, Title 23, Division 3, Chapter 18, Article 3, Section 2807. The mechanisms used to demonstrate financial responsibility as required by Section 2807 are as follows: C. Mechanism Mechanism Coverage Coverage Corrective Third Party Type Name and Address of Issuer Number Amount Period Action Comp Certificate of Insurance Old Republic MWZZ50593 1,000,000 per 06/01/2012 - YES YES Insurance Company occurrence and 06/01/2015 414 W. Pittsburgh St. 2,000,000 Greensburg, PA 15601 annual aggregate Note: If you are using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of this certification also certifies thatyou are in compliance and shall maintain compliance with all conditions for participation in the Fund. See instructions. D. Facility Name Facility Address See Attached Facility Name Facility Address Facility Name Facility Address E. Signature of Tank Owner or Operator Date Name and Title of Tank Owner or Operator Y 5 /23/12 Art Kirchoffer — Assistant Treasurer Signature of Witnes's or Nota,rj %' Date Name of Witness or Notary 5 /23/12 Edna Gilchrist CFR (Revised 0R /06) FILE: Original - Local Agency Copies - Facility /Site(s) Active-UST-list-for-FA-1 20214 Page 1 aW May 21, 2012 Bakersfield City Fire Department UST Compliance 2101 H Street Bakersfield, CA 93301 AT &T EH &S T: 214.464.3131 308 S. Akard Street #1700 F: 214.464.1424 Dallas, TX 75202 www.ehs.att.com RE: Certification of Financial responsibility - Underground Storage Tanks To whom it may concern, Enclosed please find a copy of our annual State of California Certification of financial responsibility and a Certificate of insurance to demonstrate the financial responsibility of Pacific Bell Telephone Company /dba AT &T California, AT &T Corp and /or its affiliate company for its underground storage tanks. Also enclosed please find a list of the sites that are covered by insurance and that have underground storage tanks on the premises in your area of jurisdiction. If you have any questions or require any additional information, please feel free to contact me at (214) 464.3131 or by email at sh19756batt.com. Thank you for your help complying with this requirement. Sincerely, Steven 3 Hall Manager, Environment, Health & Safety AT &T Services Inc. Attachment: Certification of Financial Responsibility List of insured sites with underground storage tanks Certificate of insurance a CERTIFICATE OF INSURANCE IJAME: Per the Attached List ADDRESS: Per the Attached List POLICY NUMBER: MWZZ50593 ENDORSEMENT: Not applicable PERIOD OF COVERAGE: June 1, 2012 — June 1. 2015 NAME OF INSURER: Old Republic Insurance Company ADDRESS OF INSURER: 445 South Moorland Road Brookfield, WI 53005 NAME OF INSURED: Subsidiaries and Affiliates of AT &T Inc. ADDRESS OF INSURED: 208 S. Akard Street Room 2731 Dallas. Texas 75202 CERTIFICATION: 1. Old Republic Insurance Company, the Insurer, as identified above; hereby certifies that it has issued liability insurance covering the following underground storage tank(s): See Schedule of Tanks on policy referenced above, for taking corrective action and compensating third parties for bodily injury and property damage caused by accidental releases in accordance with and subject to the limits of liability, exclusions. conditions and other terms of the policy arising from operating the underground storage tank(s) identified above. The limits of liability are $1,000,000 each occurrence- and $2,000,000 annual aggregate, exclusive of legal defense costs, which are subject to a separate Limit under the policy. This coverage is provided under policy number MWZZ50593. The effective date of said policy is June 1. 2012, 2. The Insurer further certifies the following v4th respect to the insurance described in Paragraph 1: a. Bankruptcy or insolvency of the insured shall not relieve the Insure- of its obligations under the policy to which this certificate applies. b. The Insurer is liable for the payment of amounts within any deductible applicable to the policy to the provider of corrective action or damaged third party; with a right of reimbursement by the insured for any such payment made by the Insurer. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in 40 CFR 280.95 - 280.102. c, Whenever requested by a Director of an implementing agency, the Insurer agrees to furnish to the Director a signed duplicate original of the policy and all endorsements. d. Cancellation or any other termination of the insurance by the Insurer, except for non- payment of premium or misrepresentation by the insured, will be effective only upon written notice and only after the expiration of 60 days after a copy of such written notice is received by the insured. Cancellation for non- payment of premium or misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum of 10 days after a copy of such written notice is received by the insured. e. The insurance covers claims otherwise covered by the policy that are reported to the Insurer within six months of the effective date of cancellation or non- renewal of the policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or termination date. Claims reported during such extended reporting period are subject to the terms, conditions, limits, including limits of liability, and exclusions of the policy. I hereby certify that the wording of this instrument is identical to the wording in 40 CFR 280.97 b)(2) and that the Insurer is licensed to transact the business of insurance in one or more states. Signature of Authorized Representative of Insurer Jodi Hartmann Senior Account Manager Old Republic Insurance Company 445 South Moorland Road Brookfield, WI 53005 02567