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POLICYHOLDER COPY <br />SIP <br />P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 <br />CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br />ISSUE DATE: 08-01-2011 <br />CITY OF SANTA ANA <br />PURCHASING DIVISION ATTN: BILL O'CONNOR <br />P. 0. BOX 1988 <br />SANTA ANA <br />CALIFORNIA 92702 <br />GROUP: <br />POLICY NUMBER: 1643445-2011 <br />CERTIFICATE ID: 1 <br />CERTIFICATE EXPIRES: 08-01-2012 <br />08-01-2011/08-01-2012 <br />SIP JOB:ALL OPERATIONS <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 indicated. <br />This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br />We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <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 #1700 - STEPHEN AMMANN - EXCLUDED. <br />ENDORSEMENT #1700 - RODNEY WARD - EXCLUDED. <br />ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2010 IS <br />ATTACHED TO AND FORMS A PART OF THIS POLICY. <br />EMPLOYER <br />HYDROBLAST <br />726 W ANGUS AVE STE G <br />ORANGE CA 92868 <br />!-1PPjA.(P' ' <br />LUUi2i S i <br />SIP <br />(REV.8-2010) M0409 <br />PRINTED : 07-15-2011 <br />