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Rpr O1 06 03:39p Public Works <br />---~~-.....~~w ~i„i. o raxiU tibO-3iA 4367 To T.nLmdsJ <br />7146473345 <br />Date gH/?C0A 11 13 qM Pey. c of q <br />CERTHOLOER COPY <br />STATE P.O. BOX 420807. SAN FRANCISCO,CA 94 1 42--0807 <br />COMPENSATION <br />INSURANCE <br />FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: pa-01-2008 GROUP <br />POLICY NUNHER: 1886779-2008 <br />cEHTIFicAT~ Ic a <br />CERTIPCA~E EXpIRC5: 02-01-2009 <br />02-01-2008/02.01-2009 <br />CITY Of SANTA ANA SG <br />DEPARTMENT OF PUBLIC WORKS <br />220 $ DAI9Y AVE <br />SANTA ANh CA 92703-4336 <br />ih.s is to cerLiy Nal we have asUed a valid Workers' Cmm~ensauon insurance potlcv .n a form approved by the <br />Ca~ito•nis Insurance Commisswner ;n the employer named be•ow for the policy paned and+cated. <br />Thu oollCy Is ncl sub;e[I to cancelfa40n by the Fund except upon 10 tlays advance .u ~dlen notice to the enlpl DVer. <br />'vL'e will also gwe yes f0 days advance 90tice should tn.i ppllgy ce cancelled pnor ce its normat expiration. <br />This cw-[i ticate of insw ante ,not at insvnnee polity and noes not amentl extend or altar the coverage afforded <br />by the polio/ hated herein, NC:wiln5tantlinq any requirement, ;arm o: condlhpn of any ~ontracl or other do_ument <br />with respect Ic wh¢h this certificate of insurance may be rssvad or to which LL may aerlaln, the insurance <br />oflerded by ditl pobcy de5enbed herein I5 Subfe Ct to all the terms Bz Cusie'~s, and CendltlOrle, of such pplipy. <br />STN-0HIZED REr"RESENTA*I ~~ / ""'s"-~`--~ <br />PHESIOENT <br />EMPLOYER'S LIAB[LITY LIMIT [NCLUOINO DEFENSE COSTS 51.000,000 PER OCCURRENCE. <br />.lv1PLCYEH <br />CLINICAL LABORATORIES OF SAN BERN AND/pR GEO <br />MONITOR ZNC <br />PD BOK 328 <br />SAN eERNARDf Np CA 92802 <br />1B15,NA <br />iaevs-osl ~ PRINTED 04-01-2008 <br />SG <br />p.4 <br />