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<br />CERTHOLDER COpy <br /> <br />STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 <br /> <br />COMPENSATION <br />INSURANCE <br /> <br />FU N C CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />ISSUE DATE: 01~16~2004 <br /> <br />GROUP: <br />POLICY NUMBER: 1643437~2003 <br />CERTIFICATE ID: 232 <br />CERTIFICATE EXPIRES: 08-01-2004 <br />08 - 01-2 003/ 08 -01-2004 <br /> <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLAZA IM-30) PO BOX 1988 <br />SANTA ANA CA 92702-1988 <br /> <br />!J ~ ~O()3 - 150 <br /> <br />This Is to certify that we have Issued a valid Worker's Compensation insurance policy in a form approved by the California <br />Insurance Commissioner to the employer named below for the policy period indicated. <br /> <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> <br />We will also give you 30 days advance notice should this policy be cancelled prior to Its normal expiration. <br /> <br />This certificate of insurance Is not an insurance policy and does not amend, extend or alter the coverage afforded by the <br />policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with <br />respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies <br />described herein is subject to all the terms, exclusions, and conditions, of such policies. <br /> <br />~ <br /> <br />,&~ <br /> <br />c <br /> <br />~ <br /> <br />AUTHORIZEO REPRESENTATIVE <br /> <br />PRESIDENT <br /> <br />EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #1600 ~ STUART SALOT, PRES - EXCLUDED. <br /> <br />ENDORSEMENT #1600 - MARTHA SALOT, S,T - EXCLUDED. <br /> <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2002 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />~i . <br />/'--,::::;+~y: L} <br /> <br />EMPLOYER <br /> <br />XEON, INC DBA: CTL ENVIRONMENTAL SERVICES <br />24404 VERMONT AVE STE 307 <br />HARBOR CITY CA 90710 <br /> <br />SCIF 1O262E <br /> <br />A"'pl Ih;, "rtifi,,","I,if,," "" l"c'wO<"m,~ tho< ",d, "OFFICIAL STATE FUND DOCUMENT' <br /> <br />¡,o'¡¡~i"E"d,O""'2004 <br />PAGE 1 OF1 <br />