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EXTENSION OF THE INFORMATION PAGE - ITEM 1 - OTHER <br />WORKPLACES <br />Policy Number: 59 WEC AC9055 Endorsement Number: <br />Effective Date: 07/03/20 Effective hour is the same as stated on the Information Page of the policy. <br />Named Insured and Address: BAY SPROUTS LLC <br />655 S MAIN ST STE 200-317 <br />ORANGE CA 92868 <br />Item 1 of the Information Page is completed to include other workplaces of the named insured: <br />600 E WASHINGTON ST, PHOENIX, AZ 85004-2303 <br />11800 FOOTHILLS BLVD, SYLMAR, CA 91342 <br />2500 N. MAIN ST, SANTA ANA, CA 92705 <br />557 MCREYNOLD'S RD, SAUSALITO, CA 94965 <br />NO SPECIFIC LOCATION IN STATE OF CO 00000 <br />1805 N 30TH ST, COLORADO SPRINGS, CO 80904 <br />301 N WASHINGTON ST., NAPERVILLE, IL 60540 <br />NO SPECIFIC LOCATION IN STATE OF WI 00000 <br />200 W ISLAND AVE, SAN DIEGO, CA 92101-6850 <br />1801 E CHESTNUT AVE, SANTA ANA, CA 92701-5001 <br />480 N ARROYO BLVD, PASADENA, CA 91103-3269 <br />201 E HARGETT ST, RALEIGH, NC 27601-1437 <br />Form WC 99 03 66 Printed in U.S.A. <br />Process Date: 05/25/20 <br />ew cF RAMwagementDMsian <br />Jy/\'x REVIEWED & APPROVED BY.- <br />V"° <br />Policy E _� RFskPjanagementAnalpt <br />