11-0201_ORANGE COUNTY CONSERVATION CORPS_Insurance Certificate-~ OP ID: PC
, RLX CERTIFICATE OF LIABILITY INSURANCE D� �D11nYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFjCATEyH2OLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERA _-A FO,F2<7Eq BY >THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE lS�lf1N INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If I( ItlIS ! D inject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this c lc t o is not confer rights to thto
certificate holder in lieu of such ondorsement(s).
j PRODucER 626-405-$031
Chapman 626-405-0585
License #0522024
P. O. Box 5455
Pasadena, CA 911'17-0455
1 Iaan"E: _
46° Ext): (A/ ) -
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EMAIL
ADDRESS:
INSRii POLICY EFF POLICY EXP
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LTR TYPE OF INSURANCE I' WVD POLICY NUMBER M_M1�DIYYYY� AAPhlD�lYYYY LIMITS
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PRODucER .ANG -9
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INSURER( JAFFORD[NG COVERAGE
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[ INSURED Orange County Conservation Cor
INSURER A; Great American Insurance Co
16699
Tai Tony Huynh
INSURER B: Carolina Casualt Ins Co
10510
1853 N. Raymond Ave.
Anaheim CA 92801
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INSURER_C : Nonprofits' insurance Alliance
10023 i
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INSURER D ;
AGGREGAT
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ELfM€7A>PLOC�._..�.�
INSURER E
PRODUCTS - GO'JcPfOP AGG $ 3,000,000
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INSURER F : -
Ellttp Ben@f $ 1,000,000
AUTOMOBILE LIABTUTY j ',
COVERAGES CERTIFICATE NUMBER;
REVISION NUMBER:
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THIS IS TOCERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRii POLICY EFF POLICY EXP
i
LTR TYPE OF INSURANCE I' WVD POLICY NUMBER M_M1�DIYYYY� AAPhlD�lYYYY LIMITS
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GENERAL LIABILITY
EACH OCCURRENCE i $ - 1,000,000
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A X GENERALX LIAEILITY ie ''� PAC5154680 07120/10
07/20111
MA IILNII-LI
AREMISES(Eaoccurrence) $ 100,000
!COMMERCIAL
- CLAIMS-hhA^E OCCUR 3
MED EXP (Any one arson � 5,000
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PERSC7NAL&AC7V1N.iURY 5 1,000,000
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GENEt2ALAGGR GATE S 3,000,000
AGGREGAT
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PRODUCTS - GO'JcPfOP AGG $ 3,000,000
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AUTOMOBILE LIABTUTY j ',
COMBINED SINGLE LIM7 fi
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{Ea aocidenf)
: ANY AUTO !,
BODILY INJURY (Per person)ALL - $
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OS
BODILY INJURY (Per accident) $
SCHODULED AU i
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PROPERTY DAMAGE
uHIREDAUTOS 1
(Per accident)
NON -OWNED AUTOS ?
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3
$
UMBRELLA LIAR OCCUR____„_ —.
EACH OCCURRENCE $
EXCESS LIAR CLAIMS -MADE
AG_GRF_GATE
_ DEDUCTIBLE
-
RETENTION $ l
$
WORKERS COMPENSATIONH-
j
XAND :ORYLiMITS ER
EMPLOYERS' LIABILITY
C ANY PRC RiETORIPARTNERlEXECUTIVEYJN NPEIWCG0012011 01/07/11
1 01101112
ii E LEACH ACCIDENT S1,000,000
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0FFICERIMEM€BER EXCLUDED? NIA
E.L. DISEASE- EA EMPLOY_EF S 1,000,000
i (Mandatory in NH)
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E. L. DISEASE -POLICY LIMIT S 1,000,000
--
A Property coverage PAC5754680 07/20/70
07120111W-
-
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedute, if mare space is required)
Re: Premise. City of San Juan Capistrano is named additional insured with
respect to the operations of the named insured. Waiver of Subrogation for
Workers Compensation policy applies in favor of certificate holder -
endorsement to follow.
C:tK I It-IUA I It MULUtK
CITYSAU
City of San Juan Capistrano
32400 Paseo Adelanto
San Juan Capistrano, CA 92675
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
O 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
—'�� A rninistr five offices
58 'Na[nuStreet
Cincinnati, Ohio 45202
RE ATAMERICAN, 19T:
lriOPR CG 82 24
(Ed. 12 011
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SOCIAL SERVICE AGENCY GENERAL LIABILITY BROADENING ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. The following provision is added to SECTION
II - WHO IS AN INSURED
5. AUTOMATIC ADDITIONAL 1NSUREDIS)
a, Additional Insured - Manager or
Lessor of Premises
(1) This policy is amended to include
as an insured any person or or-
ganization (hereinafter called Ad-
ditional Insured) from whom you
lease or rent property and which
requires you to add such person
or organization as an Additional
Insured on this policy under:
(a) a written contract; or
(b) an oral agreement or con-
tract where a Certificate of
Insurance showing that per-
son or organization as an
Additional Insured has been
issued;
but the written or oral contract or
agreement must be an "insured
contract," and,
(I) currently in effect or be-
come effective during the
term of this policy: and
(ii) executed prior to the 'bodily
injury,` "property damage,"
"personal and advertising in-
jury „
(2) With respect to the insurance af-
forded the Additional Insured
identified in Paragraph A.(1) of
this endorsement, the following
additional provisions apply:
(a) This insurance applies only
to liability arising out of the
ownership, maintenance or
use of that portion of the
premises leased to you.
(b) The Limits of Insurance ap-
plicab(e. to the Additional In-
sured are the lesser of those
specified in the written con-
tract or agreement or in the
Declarations for this policy
and subject to all the terms,
conditions, and exclusions
for this policy. The Limits of
Insurance applicable to the
Additional Insured are inclu-
sive of and not in addition to
the Limits of Insurance
shown in the Declarations.
(a) In no event shall the cov-
erages or Limits of Insurance
in this Coverage Form be in-
creased by such contract.
(d) Coverage provided herein is
excess over any other valid
and collectible insurance
available to the Additional In-
sured whether the other in-
surance is primary, excess,
Includes copyrighted material of Insurance Service Office with its permission.
Copyright, Insurance Services Office, Inc.. 2001
CG 82 24 (Ed. 12101) XS (Page 1 of 4)
contingent or on any other
basis unless a written con-
tractual arrangement specifi-
cally requires this insurance
to be primary.
(3) This insurance does not apply to:
(a) Any `occurrence" or offense
which takes place after you
cease to be a tenant in that
premises.
(b) Structural alterations, new
construction or demolition
operations performed by or
on behalf of the "Additional
Insured."
b. Additional Insured - Funding
Sources
(1) This policy is amended to include
as an Insured any Funding Source
which requires you in a written
contract to name the Funding
Source (hereinafter called Addi-
tional Insured) as an Insured but
only with respect to liability aris-
ing out of your premises, 'your
work" for such Additional Insured;
or acts or omissions of such Ad-
ditional Insured in connection with
the general supervision of "your
work" and only to the extent set
forth as follows:
(a) The Limits of Insurance ap-
plicable to the Additional In-
sured are the lesser of those
specified in the written con-
tract or agreement or in the
Declarations for this policy
and subject to all the terms,
conditions, and exclusions
for this policy. The Limits of
Insurance applicable to the
Additional Insured are inclu-
sive of and not in addition to
the Limits of insurance
shown in the Declarations.
(b) The coverage provided to
the Additional Insured(s) is
not greater than that cus-
tomarily provided by the
policy forms specified in and
required by the contract.
(c) In no event shall the cov-
erages of Limits of Insurance
in this Coverage Form be in-
creased by such contract.
c. Additional Insured - Contractual
Obligations
(1) This policy is amended to include
as an Insured any person or or-
ganization (hereinafter called Ad-
ditional Insured) that you are re-
quired by a written "insured con-
tract" to include as an Insured,
subject to all of the following
provisions:
(a) Coverage is limited to liability
arising out of:
(i) your ongoing oper-
ations performed for
such Additional Insured;
or
(ii) that insured's financial
control of you; or
(iii) the maintenance, opera-
tion or use by you of
equipment leased to
you by such Additional
Insured; or
(iv) a state or political sub-
division permit issued
to you.
(b) Coverage does not apply to
any "occurrence" or offense:
(i) which took place be-
fore the execution of,
or subsequent to the
completion or expira-
tion of, the written "in-
sured contract", or
(ii) which takes place after
you cease to be a ten-
ant in that premises.
Includes copyrighted material of Insurance Service Office with its permission.
Copyright, Insurance Services Office, Inc., 2001
CG 82 24 (Ed. 12/01) XS (Page 2 of 4)
(c) With respect to architects,
engineers, or surveyors,
coverage does not apply to
"Bodily Injury," "Property
Damage," "Personal and Ad-
vertising Injury" arising out
of the rendering or the fail-
ure to render any profes-
sional services by or for you
including:
(i) the preparing, approv-
ing, or failing to pre-
pare or approve maps,
drawings, opinions, re-
ports, surveys, change
orders, designs or
specifications, and
{iii) supervisory, inspection,
or engineering services.
If an Additional Insured endorsement is at-
tached to this policy and specifically names a
person or organization as an Insured, then the
coverage in Section II - WHO IS AN
INSURED 5. Automatic Additional Insured(s)
does not apply to that person or organization.
2. BLANKET WAIVER OF SUBROGATION
SECTION IV - COMMERCIAL GENERAL
LIABILITY CONDITIONS, Item 8. is replaced
with:
8. Transfer of Rights of Recovery Against
Others to us and Blanket Waiver of
Subrogation
a. If an Insured has rights to recover all
or part of any payment we have made
under this Coverage Part, those rights
are transferred to us. The Insured must
do nothing after loss to impair them
At our request, the Insured will bring
"suit" or transfer those rights to us and
help us enforce them.
b. If required by a written "insured con-
tract", we waive any right of recovery
we may have against any person or
organization because of payments we
make for injury or damage arising out
of your ongoing operations or "your
work" done under a contract for that
person or organization and included in
the "products -completed operations
hazard."
2. NDN -OWNED DIS CHARTERED WATER-
CRAFT
Section I - Coverages, Coverage A. Item
2.9.0 is replaced with:
(2) A watercraft you do not own that is:
(a) less than 51 feet long; and
(b) not being used to carry persons or
property for a charge.
4. BROADENED PERSONAL AND ADVERTISING
INJURY
Unless "Personal and Advertising Injury" is ex-
cluded from this policy:
SECTION V - DEFINITIONS Item 14. is re-
placed by:
14. "Personal and Advertising Injury" means
injury, including consequential 'bodily in-
jury," arising out of one or more of the
following offenses:
a. false arrest, detention or imprison-
ment;
b. malicious prosecution;
c, the wrongful eviction from, wrongful
entry into, or invasion of the right of
private occupancy of a room, dwelling
or premises that a person occupies by
or on behalf of its owner, landlord or
lessor;
d. oral, written, televised, videotaped, or
electronic publication of material, in
any manner, that slanders or libels a
person or organization or disparages a
person's or organization's goods, pro-
ducts or services,
e. oral, written, televised, videotaped, or
electronic publication of material, in
any manner, that violates a person's
right of privacy; or
Includes copyrighted material of Insurance Service Office with its permission.
Copyright, Insurance Services Office, Inc., 2001
CG 82 24 (Ed. 12/01) XS (Page 3 of 4)
f. mental injury, mental anguish, humili-
ation, or shock, if directly resulting
from Items 14.a. through 14.e.
g. the use of another's advertising idea in
your "advertisement", or
h. infringing upon another's copyright,
trade dress or slogan in your "adver-
tisement."
5. MENTAL INJURY, MENTAL ANGUISH,
HUMILIATION, OR SHOCK INCLUDED IN
BODILY INJURY DEFINITION
Section V - Definitions, Item 3. is replaced
with:
3. "Bodily injury" means physical injury, sick-
ness, or disease, including death of a per-
son. "Bodily injury" also means mental in-
jury, mental anguish, humiliation, or shock
if directly resulting from physical injury,
sickness, or disease to that person.
6. MEDICAL PAYMENTS
A. The Medical Expense Limit in Paragraph 7.
of SECTION III - LIMITS OF INSURANCE
is replaced by the following Medical Ex-
pense Limit.
The (Medical Expense Limit provided by
this policy shall be the greater of:
a. $10,000, or
b. The amount shown in the Declarations
for Medica[ Expense Limit.
B. This provision 7_ is subject to all the terms
of SECTION Ill - LIMITS OF INSURANCE.
C. This provision 7. does not apply if
COVERAGE C. MEDICAL PAYMENTS is
excluded either by the provisions of the
Coverage Part or by endorsement.
7. DAMAGE TO PREMISES RENTED TO YOU
LIMIT
A. SECTION III - LIMITS OF INSURANCE,
Item 6. is replaced with:
Subject to x. above, the Damage to Prem-
ises Rented to You Limit is the most we
will pay under Coverage A for damages
because of "property damage" to your
building, or to personal property of others
in your care, custody and control while at
premises rented to you or temporarily
occupied by you with permission of the
owner, arising out of any one fire.
The Damage to Premises Rented To You
Limit is replaced by the following Damage
to Premises rented To You Limit.
The Damage to Premises Rented To You
Limit is the greater of:
(1) $500,004: or
(2) the amount shown in the Declarations
for Damage to Premises Dented to
You Limit,
B. This provision is subject to all the terms
of SECTION III - LIMITS OF INSURANCE.
C. This provision 5. does not apply if Damage
to Premises Fent to You Liability of COV-
ERAGE A (SECTION 1) is excluded either
by the provisions of the Coverage Part or
by endorsement.
9. SUPPLEMENTARY PAYMENTS
A. In the SUPPLEMENTARY PAYMENTS -
COVERAGES A and B provision, Item 1.b.,
and 1.d are replaced with:
1.b. tip to $500 for cost of bail bonds
required because of accidents or traf-
fic law violations arising out of the use
of any vehicle to which the Bodily In-
jury Liability Coverage applies. We do
not have to furnish these bonds.
1.d. All reasonable expenses incurred by
the Insured at our request to assist us
in the investigation or defense of the
claire or "suit," including actual.loss of
earnings up to $500 a day because of
time off work_
This endorsement does not change any other
provision of the policy.
Includes copyrighted .material of Insurance Service Office with its permission.
Copyright, Insurance Services Office, Inc., 2001
CG 82 24 (Ed. 12/01) XS (Page 4 of 4)
OP 10: PC
' `C7"R ` ` CERTIFICATE OF LIABILITY INSURANCE12/15
CAATD3YYYY)
'!2115170
P #1RrG I TE1;IdAkE HOLDER. THIS
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTSMP
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CdVE" 1= AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 1 r,
p
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must he endorse !0131406A 10 IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not Confer rights to the
certificate holder in Ilou of such endorsement(s). :.
PRODUCER 626-405-8031
Chapman 626-405-0585
License #0522024
P. 0. Box 5455
Pasadena, CA 99117-0455
CONTACT -
CONT ..
PHONE � . 'i „ - ; , . , .::. FAX
M`L �xc :
ADURESS.
PRODUCER gF�ANCs
cuaTflMER D
INSURER(S) AFFORDING COVERAGE NAIC ff
_......._..,._...._,_._.-._.....___
INSURED Orange County Conservation Cor �
Tai Tony Huynh
1853 N. Raymond Ave.
Anaheim, CA 92801
INSURERA. NlonProfits United
INSURER 6:
GENERAL LIABILITY
INSURERD:
INSURER E:
INSURER E'
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBER HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSION AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
........ ...�..W
INTR
TYPE OF INSURANCE
ADDL
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+
POLICYNUMBER
PCILICY EFF
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POLJCY EXP
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LIMITS
San Juan Capistrano, CA 92675
GENERAL LIABILITY
EACH OCCURRENCE
5
OREMISES6HEF)T
1 COMMERCIAL GENERAL LIABILITY
rfonc—
Fi"2Eh115E5(f"tieLCerraRC9)
CLAIMS -MADE 17 OCCUR
1vfED EXP (Any one person)
$
PERSONAL & AEV INJURY
$
GENERAL AGGREGATE
$
GFN`LAGGREGATELIMIT APPUESPER,
PRODUGTS-COMPIOPAGG
$
POLICY _ PRO-JEQ[L.
$
A
.AUTOM081i.E
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LIAeIWTY
ANY AU"J'O
1560
0710V10
07101/11
COMB)NF'E SINGLE t. MIT
(Ea &rxidanlj
$ 1,000,€100
BODILY INJURY (Per Person)
$
AIJ_ OW NEE AUTOS
801311„Y INJURY (Par 9cnident)
5
.
SCHEWLr=O AUTOS
HIRED AUTOS
PROPERTYOAMAGE
€Pe3• scc€den!)
$
NON•owNEDAUTos
UMBRELLA LIAROCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAIS CLAIMS -MADE
$
WDUCTtKIE
!
RETENTION
WORKERS COMPENSAMN
WC 'TATO• OTH-
AND EMPLOYERS' LIABILITY Y N
-----------
ANYPROPRIErORfPARTNERIEXECUTIVE�
0PFICERiMEMBEREXCLUD7
N/A
-
E,L,EACIIACClOENT
-...... _......W...._.___.__.,_..
$ ._._,_
(Mandatary in NH)
E.I.„ EISEASC» EA EMPLOYE r
$ ._._ ��
I{Yes. dbsr.•riinr� under
W9GRIPTM OP OPERATIONS helaw
F.L. DISEASE- POLICY LIMIT
$
13rsc lPTION OP OPERATIONS! LOCAT€ONS 1 VIEHICLES (Attach ACORD IN, AddWonal Remarks Sched0a, If mora epa� Is required)
Evidence of coverage, 10 days notice of cancellation for non-payment of
premium.
rP:RTIFI('.ATF Hf)i nFR rAKICF.1_.I ATION
C iTYSAU
SHOULD ANY OF THE ABOVE DESORISE13 POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of San Juan Capistrano
324.00 Paseo Adelanto
AUTHORtzEPREFRESENTATtVE
San Juan Capistrano, CA 92675
C 1388-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
�E-Verff
Company ID Number: 390867 C
2611 1 F8 t 0 A
To be accepted as a participant in E -Verify, you should only sign the Employer's Section
of the signature page. If you have any questions, contact E -Verify
&
...... .........
....... . . ..... ............................................................................................................ ................................................................................................. ........ ............................................................................................... . . ..... ... ... .. ....
Employer Orange County Conservation Corps
Tonv Huvnh
----- -------------- -------------- ------------- . ...... .... ..... ....... ... .. ...
Name (Ptease Tvpe or Print)
1
rtment of Homeland Security — Verification Division
ISCIS Verification Division
......... . . ... ........ .................. .......... ............ . . . . .... T. 1.1.111, . . .. ......... .....
ame ease Type or Print) Title
lectronicaliv Signed 02/08/2011
ate
Information Required for the E -Verify Program
nformation relatinci to vour Cornmw
Company Name: range County Conservation
Company Facility Address -.111863 N. Raymond Ave.
Company . .. ..... .. ... .. ... ...... ....... ....
Anaheim, CA 92801
Company Alternate
Address:
County or Parish: ORANGE
Employer Identification
Page 12 of 13 1 E -Verify NEO U for Employer I Revision Date 09/01109 www.dhs.gov/E-Verify
Company ID Number: 390867
...........
North American Industry
Information relating to the Program Administrator(s) for your Company on policy
questions or operational problems:
Nance:
` G11V Iluvnh
`€'elepho}ne Number:
(714) 956 - 6222 Fax Numlxr: (714) 956 - 1944
€ -mail Address:
thuynh!