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AGENCY CUSTOMER ID: ONYXPAV-01 <br />_ LOC #: <br />ACCORl7® ADDITIONAL REMARKS SCHEDULE Page 1 of 1 <br />AGENCY <br />Burnham WGB Insurance Solutions <br />NAMED INSURED <br />Ong Paving Company, Inc. <br />2890 E. La Crests Avenue <br />Anaheim CA 92806-1816 <br />POLICY NUMBER <br />CARRIER <br />NAIC CODE <br />EFFECTIVE DATE: <br />THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, <br />FORM NUMBER: 26 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE <br />Additional Insured, Primary & Non -Contributory, and Waiver <br />Waiver of Subrogation Form #WC 04 03 06 <br />Job #23-054. Local Street Preventative Maintenance Project <br />iFlcate Holder Vesting: <br />of Santa Ana <br />ACORD 101 (2008101) <br />04 <br />reserved. <br />The ACORD name and logo are registered marks of ACORD <br />