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Workers' Compensation Professional Employer Organization (PEO) Do you lease employees through Professional Employer Organization? No Workers' Compensation Overview Insured by carrier Carrier: XL Specialty Insurance Policyholder Name: LINl I'F.D STORM WATER, Inc. Policy Number: Wi:C30011.35 Certification Inception Date: December 31, 2019 Expiration Date: December 31, 2020 Yes I certify that I do not have any delinquent liability to an employee Or the State for any assessment of back wages or related damages, interest, fines, or penalties pursuant to any final Judgment, order, or determination by a court or any federal, state, or local administrative agency, including a confirmed arbitration award Yes I certify that the contractor is not currently debarred under Section 177J.1 or under any other federal or state law providing for the debarment of contractors from public works YesI certify that one of the following Is true: (1) 1 am licensed by the Contractors State License Board (CSLB) in accordance with Chapter 9 (commencing with Section 1000) of the Business and Professions Code; or (2) my business or trade is not subject to licensing by the CSLB. I understand refunds are not authorized I, Marisa Piro, the undersigned, am , UNITED STORM WATER, INC with the authority to act for and on behalf of the above named contractor. I certify under penalty of perjury that all of the above information provided if true and Correct. I further acknowledge that any untruthful information provided in this application could result in the certification being canceled - I certify this on: 6/23/2020 6:44:34 AM Legal Entity Information Legal Entity Type: Corporation Name. UNITED STORM WATER, INC Reglstratlon Services:: Page 2 of 2 S ubsp; C;ily Council &nhsp;26 lndash:lnhsp;170 o/15/2021 @nhsp;