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'``C °RO CERTIFICATE OF LIABILITY INSURANCE <br />`✓'� <br />DATE <br />/5 /2014 Y) <br />6/5/2014 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, <br />IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER 0009892 <br />Adler Belmont Dye Insurance Services, Inc. <br />369 Marsh Street <br />Spite 200 <br />San Luis Obispo CA 93401 <br />CONTACT B <br />NAME: xitni Parsons <br />PNONE (805)540 -3900 aC NO•I005)$40 -3901 <br />ik:.b;ar;ons@adlerbGlmontdye.com <br />INSURERS AFFORDING COVERAGE <br />NAtC4 <br />INSURERA:North River Insurance Company <br />1105 <br />INSURED <br />San Luis Butane Distributors, Inc. <br />(See attached for Additional Named Insureds) <br />1960 Ramada Drive <br />Paso Robles CA 93446 <br />INSURERB;United States Fire Insurance CO <br />21113 <br />INSURER C:Insurance Company of the West <br />27847 <br />INSURCRD;Lexington Insurance Company <br />9437 <br />INSURER E: <br />$ 1,000,000 <br />1 INSURER F: <br />X COMMERCIAL GENERAL LIABILITY <br />COVERAGES CERTIFICATE NUMBER:13 -14 Master REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />DDLSUOR <br />POLICY NUMBER_ <br />POLICY EFF <br />MMIbDNYYY <br />POUCYEXP <br />IDp <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />X COMMERCIAL GENERAL LIABILITY <br />PREMISES (Ea <br />$ 50, 000 <br />A <br />CLAIMS-MADE OCCUR <br />X <br />06- 0746414 <br />/29/2033 <br />/29/2034 <br />MEO EXP(An one Person) <br />S 10,000 <br />PERSONAL &ADV INJURY <br />$ 1,000,000 <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />GEN'L AGGREGATE <br />LIMIT APPLIES PER: <br />PRODUCTS AGG <br />$ 2,000,000 <br />X POLICY <br />PRO- LOG <br />$ <br />AUTOMOBILE <br />LIABILITY <br />MBCN-D INGLE 1 <br />I <br />11000,000 <br />A <br />ANY AUTO <br />BODILY INJURY (Per person) <br />$ <br />Ix <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />06- 8746414 <br />/29/2013 <br />/29/2014 <br />pODILV INJURY Per eccldont <br />( I <br />$ <br />HIRED AUTOS X AUTOS <br />(Per accident AMAGE <br />$ <br />Medical memo <br />$ 5,000 <br />UMBRELLA LIA6 <br />X <br />OCCUR <br />EACH OCCURRENCE <br />$ 9,000,000 <br />AGGREGATE <br />$ 9,000,000 <br />B <br />X <br />EXCESS UAB <br />CLAIMS-MADE <br />OED I X I RETENTION$ 10,00 <br />$ <br />23- 7081046 <br />/29/2013 <br />/29/2014 <br />C <br />WORKERS COMPENSATION <br />X I WCSTATU- I O7H- <br />FR <br />AND EMPLOYERS' UABIUTY YIN <br />E.L. EACH ACCIDENT <br />$ 1 000 000 <br />ANY PROPRIETORIPARTNERIEXECUTIVE <br />OFFICERNEMBER EXCLUDED? <br />NIA <br />E.L. DISEASE • EA EMPLOYE <br />$ 1 000 000 <br />(Mandatory in NH) <br />SA 5006073 02 <br />0/1/2013 <br />0/1/2014 <br />H yes, descnbo under <br />E.L. DISEASE- POLICY LIMIT <br />$ 1 000 000 <br />DESCRIPTION OF OPERATIONS twl. <br />D <br />Excess Liability <br />49883239 <br />/29/2013 <br />/29/2014 <br />Aggregate Liability 6,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mom apace is to ad) <br />City of Santa Ana, its officers, employees, agents, volunteers, an v itional Insured <br />with respects to General Liability per form CG2026 (07/04). <br />RE: Now propane Fueling Station -Fleet Services <br />lase Sandov <br />S nior Assistant City Attorney <br />CERTIFICATE HOLDER CANcELLATIdN <br />ACORD 25 (2070105) ©1988 -2010 ACORD CORPORATION. All rights reserved. <br />INS025 Go1oo5).o1 The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />City of Santa Ana <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />AUTHORIZED REPRESENTATIVE <br />Santa Ana, CA 92702 <br />Dave Belmont /CINDY <br />ACORD 25 (2070105) ©1988 -2010 ACORD CORPORATION. All rights reserved. <br />INS025 Go1oo5).o1 The ACORD name and logo are registered marks of ACORD <br />