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10/04/2009 20:33 <br />STATE <br />IX P RSATHM <br />.FUND <br />ISSUE DATE: 10-0 <br />CITY OF SANTA ANA <br />20 CIVIC CMER PL <br />UNTA ANA CA 029'01 <br />This is to certify that <br />California Insurance G <br />This policy is not <br />CERTHO AER COPY <br />SC <br />P.O. BOX 420807, SAN FRANCISCQCA 84142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />GROL F: <br />POLICY NUMBER: 1777140-2000 <br />CERTIFICATE ICk 470 <br />CERTIFICATE EXPIRE& 02-211.2010 <br />02-21-200/02-21-20`10 <br />THIS CERTIFICATE SUPERSEDES AND ACTS <br />CERTIFICATE # 070 DATED 10-00-0000 <br />SC <br />have Issued a valid Workers' Compensation Insurance policy in a tam approved by the <br />issianer to the employer named below for the policy period indicated. <br />to cancellation by the Fund except upon g0 days advance written notice to the employer. <br />We will also yive you 40 days advanca notice should this policy be cancelled prior to its normal expiration. <br />This eertMlcate of km ce is not an insurance policy and does not arnMld. extend or alter the opvrrage afforded <br />by the policy listed her irL Notwithstardkv any reWirernenk term or condition of " contract or other document <br />with respect to which certificate of Inswance may be issued or to which it may pertain the insurance <br />afforded by the policy abed herein is'sub)ect to all the terms, exclusions, and conditions, of such policy, <br />HQRIZED R EPRESIDENT <br />ENPWYMR,1S LIABIL TY LIMIT :NOLUDINC DEFENSE COSTS; $1,000,00D PER O=RRD CB- <br />EMDORSil111111lUfl #0015 ENTITLED ADDITIONAL INSIJRlD F,IIPLOYER EFFECTIVE 2000-10-02 IS <br />ATTAt$M TO AND FIRM A PART OF THIS POLICY. NAME OF ADDITIONAL INWRED: <br />CITY OF SHWA ANA <br />ENOORSFONT #IBM - DANES SKAFF P,S T - EXCLUDED. <br />ENDORSEMENT #1000 - TERRY D BNITH VPRES - EXCLUDED. <br />EIDORSUBIT #2006 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 02-21-2006 IS <br />ATTACH90 TO AM Fdii A PART OF THIS POLICY. <br />EMPLOYER <br />DIXIE DIESEL A EL! <br />DIESEL ii1NAN RESM <br />8180 MAXSdi RD <br />IL ilRMtTO CA 01795 <br />REM-= <br />APPROVED AS TO FORM <br />r <br />tiaura Stitt SA?ttoedy <br />rney <br />Assistant City <br />C. INC AND/OR DIXIE XC <br />NONT CO INC <br />APPROVED AS TO FORM <br />aura Stitt Sheedy <br />Assistant City Attorney <br />Is11,scl <br />POINTED : 10-02-2000 <br />#2000 P.004/010