HomeMy WebLinkAbout1520 20TH STREET (16)State of California For State Use Only
State Water Resources Control Board
Division of Financial Assistance
v P.O. Box 944212
Sacramento, CA 942"-2120
CERTIFICATION OF FINANCIAL RESPONSIBILITY
FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM
A. I all mxluvell Indenk,nstrate I'illalcial ResIx,mtlnliry in the.. relluirett aOUWIK m spe6fwd in CCR, lisle 23 Nvislon 3, Charier I9, tiittii.n 2907:
500,000 dollars per occurrence I million dollars annual aggregate
or AND or
I million dollars per occurrence ® 2 million dollars annual aggregate
herebv certifies that ii is in compliance with the recluirenents of California 'ode of
AT &T CORP. Regulations, Title 23, Division 3. Chapter 18, Article 3, Section 2807.
IN of_k0", a111cieoxl
The mechanisms used to demonstrate financial sponsibility as re uired by Section 2807 are as follows:
C. Mechanism Name and Address of Issuer Mechanism Coverage Coverage Corrective Third Party
r Number Amount Period Action Compensation
1,000,000
Old Republic Insurance per
Certificate of Company occurrence 6/1/2010 - MWZZ50517 and Yes YesInsurance414W. Pittsburgh St. 6/1/20122,000,000Greenburg, PA 15601 annual
aggre ate
Note: 11 you are using the State Fund Lis any pan of your demonstration of financial responsihility, your execution and submission of this certification also
certifies that ou are in atn liance and shall remain in con liance with all conditions fur r.lrtici cation in the Fund.
D. r inly N.— r,iily Adk...
See attached list of locations
F:.:dny Nairn I' iliry Add—,
R.flh.y N- P;wilin' iW trec.
F,J,,y Na F..Jily Addr—
F.: ilni Na F.. Oily Ad,h...
V-ilq Nair I.w'JilyAibh
r;u slily Nu I:,. JayA&hm
w: aria a r.gxr In )
t
11— Nnrne 0 I'i11e ,l rsnk lh..xr n l )t ra
5/11/2011 Elaine Lou
gyp, rc iuin n ..:v)' Itnl. Nulnrr Wnnrc..x lJ V,uy
G 5/1 1/201 1 Edna Gilchrist
fiubmit original to local UST regulatory agency. Keep a copy at each LIST facility.
ttN -(W9 • 1/3 NNN.Illlld(7QS.1/rl Rev. 10/16/06
CERTIFICATE OF INSURANCE
NAME: Per the Attached List
ADDRESS: Per the Attached List
POLICY NUMBER: MWZZ50517
ENDORSEMENT: Not applicable
PERIOD OF COVERAGE: June 1, 2011 —June 1, 2012
NAME OF INSURER: Old Republic Insurance Company
ADDRESS OF INSURER: 445 South Moorland Road
Brookfield, WI 53005
NAME OF INSURED: AT &T Inc. and Subsidiaries
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 MWZZ50517. The effective date of said policy is June 1, 2010.
2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1:
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.
C12567 CADOCUME- 1 \JLHART -1\ LOCALS -1 \Temp \notesE1EF34 \- 7604690.doc
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
sta es.
Signature of Authorized Representative of Insurer
Jodi Hartmann
Senior Account Manager
Old Republic Insurance Company
445 South Moorland Road
Brookfield, WI 53005
C12567
Location Code Addressl city County AT &T Tank IDI Tank Capacity Material Stored ATT Entity CUPA
SA004 1918 M STREET BAKERSFIELD Kern SA004U001 20149 DIESEL FUEL #2 LOW SULFUR Pacific Bell Telephone Company Bakersfield Ci Fire
SA098 3221 S. H STREET BAKERSFIELD Kern SA098UO01 6016 DIESEL FUEL #2 LOW SULFUR Pacific Bell Telephone Company Bakersfield City Fire
State of California For State Use Only
t State Water Resources Control Board
t I Division of Financial Assistance
P.O. Box 944212
Sacramento. CA 94244-2120
CERTIFICATION OF FINANCIAL RESPONSIBILITY
FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM
A. I am required to denroacuate tin:ncml Reslwnsibility in Irx required aukrunts as :pYiticd in CCR.'fiile'_13 Division 3, Chapu•i 18, Section 28117:
500,000 dollars per occurrence 1 million dollars annual aggregate
or AND or
I million dollars per occurrence ® 2 million dollars annual aggregate
B. Pacific Bell Telephone Company dba. AT &7 hert-hy cenifit-s that it is in compliance with the requiremr -ms of California COdt. of
Regulations, Title 23. Division 3, Chapter 19, Anicle 3. Section 2907.
California
N—,u —1 <: m .,C1 --i
The mechanisms used to demonstrate financial r sponsibility as re uired by Section 2807 are as follows:
C. Mechanism Name and Address of Issuer Mechanism Coverage Coverage Corrective Third Party
Type Number Amount Period Action Compensation
1,000,M)o
Old Republic Insurance per
Certificate of Company occurrence 6/1/201U- MWZZ50517 and Yes YesInsurance414W. Pittsburgh St. 6/1/20122'000'000
Greenburg, PA 15601 annual
aggregate
Nose: If you arc using the State Fund as any pan of your demonstration of financial responsihility, your execution and submission of this certilication also
certifies that You are in com liancc and shall remain in com liance with all conditions for participation in the Fund-
H"10 NrnrD. F,rilily Addr-
See attached list of locations
F-ilily N— Flih, 4.ld—
1 :,,iliiy Near Iv; iNq Ad.ho,
Fa: dil, Nair I':,. ililv AJ hr+-.
V,iliiy Nanr F.r Rky.41Jrna
I ..: i1a, N.— I ilny Ad&—
F—Iny Na— I :ardnp Add —
F. — ian:riore, i'r n rha a ( l to- N— :rM'nrk ,n 'IuiA rh,rm n rrn
5/11/201 1 Daniel V. James - Assistant Treasurer
JIM i—w Y I?— Nero• IN'il—s rt N,rary
k 1k-i, C b`, 5/1 1/201 1 Edna Gilchrist
UN -049 - 113 www.tt»idocs.org Rev. 11106/06
CERTIFICATE OF INSURANCE
NAME: Per the Attached List
ADDRESS: Per the Attached List
POLICY NUMBER: MWZZ50517
ENDORSEMENT: Not applicable
PERIOD OF COVERAGE: June 1, 2011 — June 1, 2012
NAME OF INSURER: Old Republic Insurance Company
ADDRESS OF INSURER: 445 South Moorland Road
Brookfield, WI 53005
NAME OF INSURED: AT&T Inc. and Subsidiaries
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 polity. This coverage is provided
under policy number MWZZ50517. The effective date of said policy is June 1, 2010.
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.
C12567 CADOCUME- 1 \JLHART -1 \LOCALS -1 \Temp \notesE1EF34 \- 7604690.doc
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
sta es.
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 State Use Only
State Water Resources Control Board
Division of Financial Assistance.
44P.O. Box 9212
Sacramento, CA 94244-2120
CERTIFICATION OF FINANCIAL RESPONSIBILITY
FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM
A. I am required to denkmsuate 1"immcial Respoaslhihry In tt required am unls as sprtificd in CCR. fille'_'3I)ivision 3, Chaplet 18, Section 213117:
500,000 dollars her occurrence 1 million dollars annual aggregate
or AND or
I nullion dollars per occurrence ® 2 million dollars annual aggregate
B. Pacific Bell Telephone Company dba. AT &T hereby certiflry that it is in compliance with the requirements of California Odc- of
Regulations, Title 23, Division 3, Chapter 18, Article 3. Notion 2807.
California
N- 4—LCi— „1k YOlY1
The mechanisms used to demonstrate financial r sponsibility as re uired by Section 2807 are as follows:
C. Mechanism Name and Address of Issuer Mechanism Coverage Coverage Corrective Third Party
Type Number Amount Period Action Compensation
1,000,000
Old Republic Insurance per
Certificate of Company occurrence 6/1/2010 -
Insurance 414 W. Pittsburgh St. MWZZ50517 and 611/2012 Yes Yes
Greenburg, PA 15001 2,000,000
annual
aggregate
Note: If you are using the Slate Fund as any pan of your demonstration of financial responsihility, your execution and suhmission of this certification also
certifies that You are in cum liance and shall remain in compliance with all conditions for participation in the Fund-
1). Frili,} N— V. ilily Addr-
See attached list of locations
I °a. iliqNonr Pariliq 4ddrrss
Ps. ili(y Naur Pnrtlin Ad.hn
V-1ay Nan, Feriliiy A.hh—
I'—lity N-r F,ilu) .Add —,
F ,ili, N-i, I e,iikv Ad.h—
I'—joy N— Fail"y AM—
El sipnaeue,iT +nlc (>w Ri I!mr N— eni'I i(k of '1.1,(mn:n Irrrain
5/1 1/201 1 Daniel V. James - Assistant Treasurer
a M Itvt iH lr I ?air Vei—iN'ilrr +r x N.,ai
ll
5/11/2011 Edna Gilchrist
UN -049 - 1/3 www.unidoes.org Rev. 10/16/06
CERTIFICATE OF INSURANCE
NAME: Per the Attached List
ADDRESS: Per the Attached List
POLICY NUMBER: MWZZ50517
ENDORSEMENT: Not applicable
PERIOD OF COVERAGE: June 1, 2011 —June 1, 2012
NAME OF INSURER: Old Republic Insurance Company
ADDRESS OF INSURER: 445 South Moorland Road
Brookfield, WI 53005
NAME OF INSURED: AT &T Inc. and Subsidiaries
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 MWZZ50517. The effective date of said policy is June 1, 2010.
2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1:
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.
C12567 CADOCUME- 1 \JLHART -1 \LOCALS -1 \Temp \notesE1EF34 \- 7604690.doc
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
sta es.
Signature of Authorized Representative of Insurer
Jodi Hartmann
Senior Account Manager
Old Republic Insurance Company
445 South Moorland Road
Brookfield, WI 53005
C12567
aW
May 13, 2011
UST Compliance
Bakersfield City Fire Department
2101 H Street
Bakersfield, CA 93301
RE: Letter of Transmittal
FedEx 7970 -7517 -7471
To whom it may concern,
Enclosed please find copy(ies) of:
Certification of Financial Responsibility for the locations mentioned on the attached
list(s).
Please return applicable approval pages to:
Steven 3 Hall
C/O AT &T EH &S
308 South Akard St. Room 1700
Dallas, TX 75202
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.
CC: AT &T EH &S National Tank File Retention
W1—d Sponsor of the .5 Olympic Team
Location Code I Addressl I city Coun AT &T Tank ID Tank Capacity Material Stored I ATT Entity CUPA
CAK010 11520 20TH STI BAKERSFIELD I Kern I CAK01 00001 8000 1 DIESEL FUEL #2 LOW SULFUR I AT &T Corp. Bakersfield City Fire