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Docusign Envelope ID: 1864F19A-F7D4-458B-8446-6741 BF1 E1158 <br /> POLICYHOLDER COPY <br /> SP <br /> STATE <br /> P.O. BOX 8192, PLEASANTON, CA 94588 <br /> FUND <br /> CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> ISSUE DATE: 07-14-2025 GROUP: <br /> POLICY NUMBER: 9088276-2025 <br /> CERTIFICATE ID: 290 <br /> CERTIFICATE EXPIRES:08-04-2025 <br /> 04-26-2025/08-04-2025 <br /> THIS CERTIFICATE SUPERSEDES AND CORRECTS <br /> CERTIFICATE # 268 DATED 04-26-2025 <br /> CITY OF SANTA ANA SP <br /> 20 CIVIC CENTER PLZ # M-21 <br /> SANTA ANA CA 92701-4058 <br /> This is to certify that we have issued a valid Workers' Compensation insurance policy 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 above. <br /> This certificate of insurance is not an insurance policy 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 /> Authorized Representative President and CEO <br /> EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 04-26-2024 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> ENDORSEMENT #2572 ENTITLED BLANKET WAIVER OF SUBROGATION EFFECTIVE <br /> 2025-04-26 IS ATTACHED TO AND FORMS A PART OF THIS POLICY <br /> ENDORSEMENT #1651 - DONALD THORNE, CEO - EXCLUDED. <br /> EMPLOYER <br /> OMEGA ENVIRONMENTAL SERVICES, INC. SP <br /> 1133 CAMELBACK ST UNIT 7261 <br /> NEWPORT BEACH CA 92658 <br /> [P13,H0] <br /> (REV.7-2014) PRINTED : 07-14-2025 <br />