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<br />~~ <br /> <br />CERTHOLDER COPY <br /> <br />STATE <br />COMPENSATION <br />INSURANCE <br />I=UND <br /> <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br /> <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> <br />GORDON & WILLIAMS <br /> <br />SC <br /> <br />GROUP: <br />POLiCY NUMBER: 1717797-2004 <br />CERTIFICATE ID: 377 <br />CERTIFICATE EXPIRES: 11-01-2005 <br />11-01-2004/11-01-2005 <br />THIS CERTIFICATE SUPERSEDES AND CORRECTS <br />CERTIFICATE # 304 DATED 12-23-2004 <br />.JOB:NORTHWEST CORNER OF SANTA ANA BLVD <br />& ROSS ST., SANTA ANA, CA <br />(FILE NO. 18811> <br /> <br />ISSUE OATE: 09-30-2005 <br /> <br />2 FARADAY <br />IRVINE CA 92818 <br /> <br />, <br /> <br />This is. to certify that we ha'll8 issued a valid Workers' Compensation insurance polley in a form approved by the <br />California Insurance Commissioner to the employer named below for the policy period that will expire or did <br />expire as indicated abo\te. <br /> <br />This certificate of Insurance is not an insurance poli'cy and does not amend. extend or alter the coverage afforded <br />by the policy listed herein. Notwithstanding any requirement. term or condition of any contract or other document <br />with respect to. which this certificate of insurance may be issued or to which it may pertain. the insurance <br />afforded by the policy described herein is subject to all the terms. exclusions. and conditions. of such policy. <br /> <br />~ <br /> <br />jj.~ t <br /> <br />~ <br /> <br />AUTHORIZED REPRESENTATIVE PRESIDENT <br /> <br />EMPLOYER'S LIABILJTY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> <br />ENDORSEMENT #1800 - EDWARD F HILL PRESIDENT SECRETARY - EXCLUDED. <br /> <br />ENDDRSEMENT #lBOO - MICHAEL SAVAGE VICE PRESIDENT TREASURER - EXCLUDED. <br /> <br />ENDDRSEMENT #2085 ENTITLED CERTIFICATE HDLDERS' NOTICE EFFECTIVE 11-01-2003 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> <br />ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2005-08-30 IS <br />_ ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br />GORDON & WILLIAMS <br /> <br />RECEIVED <br />OCT Ii 5 .2/HFi <br /> <br />EMPLOYER <br /> <br />GORDON &. WILLIAMS <br /> <br />GEOTECHNOLOGIES INC <br />439 WESTERN AVE <br />GLENDALE CA 91201 <br /> <br />SC <br /> <br />-,;,', <br /> <br />'/ C" <br /> <br />,,," <br /> <br />. , <br /> <br />{REV.2-Q51 <br /> <br />.' f}J;' <br />. .~. iLl <br />~*~---- <br />.--- -"-' . ... ,. <br />..---- . ,,[,tt "I"~edy <br />Laura " c .... '... <br />Assistant Ci.ly A.\ 1. 0 1\\'.:'- <br /> <br />[B19,SC] <br />PRINTED 09-30-2005 <br />