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HomeMy WebLinkAboutUNDERGROUND TANK ,- 'i -- .. . 7R r;;µ., p e-L- ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE Page 1 of 2 7/1/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willis Insurance Services of California, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR One Bush Street, 9~ Floor ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. San Francisco, CA 94104 INSURERS AFFORDING COVERAGE INSURED INSURER A: Indian Harbor Insurance Company Safeway Inc. INSURER B: 5918 Stoneridge Mall Road INSURER C: Pleasanton, CA 94588-3229 INSURER D: I INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I~f: TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS ~ERAL LIABILITY EACH OCCURRENCE $ n COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ L Jj CLAIMS MADE [0 OCCUR MED EXP (MY one person) $ "= PERSONAL & ADV INJURY $ - GENERAL AGGREGATE $ O'L AGGREOE LIMIT APDiS PER: PRODUCTS - COMP/OP AGG $ POLICY P,~P.T LOC $ ~TOMOBllE liABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ~ = ALL OWNED AUTOS BODILY INJURY (Per person) $ = SCHEDULED AUTOS i== HIRED AUTOS BODILY INJURY (Per accident) $ NON-OWNED AUTOS F FI PROPERTY DAMAGE $ (Per accident) RGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESS LIABiliTY EACH OCCURRENCE $ o OCCUR !OJ CLAIMS MADE AGGREGATE $ $ 8 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND Inl WC STATU- Inl 0J~- EMPLOYERS' LIABiliTY E.L EACH ACCIDENT $ E.L DISEASE - EA EMPLOYEE $ E.L DISEASE - POLICY LIMIT $ A OTHER UST Financial PECOOO0956401 7/1/04 7/1/07 $1,000,000 Each occurence Repsonsibility $2,000,000 aggregate DESCRIPTION OF OPERATIONS/LOCATlONSNEHIClESlEXClUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS See attached certificate of insurance CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER lETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WilL ENDEAVOR TO MAIL 3.CL.- DAYS WRITTEN State Water Resource Control Board NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE lEFT, BUT FAilURE TO DO SO SHAll Division of Clean Water Programs Underground Storage Tank Program IMPOSE NO OBLIGATION OR liABiliTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1001 I Street, 1 7~ Floor REPRESENTATIVES. Sacramento, CA 95814 AUTHOR~E~PRESE~~E I Ir _ ... ACORD 25-5 (7/97) © ACORD CORPORATION 1988 .. Page 2 of 2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-5 (7/97) 'i / FINANCIAL RESPONSIBILITY - CERTIFICATE OF INSURANCE FEDERAL UNDERGROUND STORAGE TANK (UST) NAME: Safeway Inc. and all subsidiaries ADDRESS: 2100 White Lane Bakersfield, CA POLICY NUMBER: PECO00095640 1 PERIOD OF COVERAGE: July 1,2004 to July 1, 2007 NAME OF INSURER: ADDRESS: Indian Harbor Insurance Company c/o XL Environmental, Inc. 520 Eagleview Blvd, P. O. Box 636 Exton. PA 19341-0636 NAME OF INSURED: ADDRESS OF INSURED: Safeway Inc, and all subsidiaries 5918 Stoneridge Mall Road Pleasanton, CA 94588-3229 1. Indian Harbor Insurance Company, the Insurer, as identified above, hereby certifies that it has issued liability insurance covering the following underground storage tanks(s): # of Tanks Facility Name Facility Location 3 Store.# 2512 2100 White Lane Bakersfield, CA Safeway Inc. for taking corrective action and/or compensating third parties for bodily injury and property damage caused by either sudden accidental releases or non sudden accidental releases or 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, $2,000,000 aggregate exclusive of legal defense costs, which are subject to a separate limit under the policy. This coverage is provided under PEC000956401. The effective date of said policy is July 1, 2004. ENSTE843 (9/02) FEDUST-CERT Page lof2 ----, . /' 2. The Insurer further certifies the foIlowing with respect to the insurance described in Paragraph I: a) Bankruptcy or insolvency of the insured shaIl 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 a 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 the Director of an implementing agency, the Insurer agrees to furnish to the Director a signed duplicate original of the policy and all endorsements. d) CanceIlation or any other termination of the insurance by the Insurer, except for non-payment of premium or misrepresentation by the insured, wiIl 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. CanceIlation for non-payment of premium or misrepresentation by the insured will be effective only upon written notice and only after the expiration of a minimum of 10 days after a copy of such 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 canceIlation or non-renewal of the policy except where the new of 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 ate. Claims reported during such extended reporting period are subject to the terms, conditions, limits, including limits ofliability, 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, or eligible to provide insurance as an excess or surplus lines insurer, in one or more states, ,#<- ~ Signature of Authorized Representative of Insurer Eric Nielsen Type Name Underwriter, Authorized Representative XL Environmental, Inc. 520 Eagleview Boulevard P.O. Box 636 Exton, PA 19341-0636 ENSTE843 (9/02) FEDUST-CERT Page 2 of2 ;- ;Þ / Ci:\ ~ SAFEWAYINC, 4410 ROSEWOOD DRIVE .. PLEASANTON, CA 94588-3492 Certification of Financial Responsibility Safeway Inc. hereby certifies that it is in compliance with the requirements of subpart H of 40 CFR part 280. The [mancial assurance mechanism used to demonstrate financial responsibility under subpart H of 40 CFR part 280 is as follows: Mechanism: Issuer: Amount of Coverage: Insurance Policy Indian Harbor Insurance Company $1,000,000 each claim $2,000,000 aggregate Effective Period of Coverage: 7 /1/04-7 /1/07 Type of Coverage: Taking corrective action and compensating third parties for bodily injury and property damage caused by accidental releases. S. AFE~ J~Li Gail Kiyomura, CPCU, ARM Director of Insurance Corporate Risk Management 7/1/04 ~1ltt/w é gnature of witness) ~/1I1à.- l1,-¡ler (N e of wItness) 7/1/04 ~Recycled ~Paper