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sat:of California California Integrated Waste Management Board <br /> CERTIFICATE OF SELF-INSURANCE AND RISK MANAGEMENT <br /> (If additional space is needed,add attachment.) <br /> 0 r Address <br /> Solid Waste Division <br /> San Joa Coun 1810 E.Hazelton Ave.,Stockton,CA 95205 <br /> Risk 1i ger_ Address(if different from above) <br /> G� Canlis Building,Room 106 <br /> Ric 'etz 1 24 S.Hunter St.,Stockton,CA 95202 <br /> Solid Waste Disposal Facilities Covered: (Enter Information For Each Facility) LLbIITS OF <br /> LIABILITY <br /> Facility Per Annual <br /> Name Address Information OccurrenceAggregate' <br /> Number <br /> North County 17900 E. Harney Lane <br /> Recycling Center Lodi, CA 39-AA-0022 $ 1,000,000 $ 1,000,000 <br /> &Sanitary Landfill <br /> Corral Hollow 31130 S. Corral Hollow Rd. 39-AA-005 $ 1,000,000 $1,000,000 <br /> Sanitary Landfill Trac , CA <br /> Foothill Sanitary 6484 N.Waverly Rd. 39-AA-0004 $ 1,000,000 $1,000,000 <br /> Landfill Linden, CA <br /> Harney Lane 14750 E. Harney Lane <br /> Sanitary Landfill Lodi, CA 39_AA_0003 $ 1,000;000 $1,000,000 <br /> TOTAL: TOTAL : <br /> $4,000,000 $4,000,000 <br /> °Excluding legal defense costs <br /> CERTIFICATION: <br /> . 1. The operator and risk manager named above hereby certify that the facilities listed above are self-insured for <br /> third party bodily injury and property damage in connection with the operator's obligation to demonstrate <br /> financial responsibility under Title 14,California Code of Regulations,Division 7,Chapter 5,Article 3.3. The <br /> coverage applies to the above-listed facility(ies)for accidental occurrences arising from the operations of the <br /> facility(ies). • <br /> 2. The limits of liability are the amounts stated above for`per occurrence"and"annual aggregate",exclusive of l <br /> legal defense costs. r <br /> 3. Coverage is primary <br /> i <br /> 4. Upon request by the Board,the operator agrees to furnish to the Board any documents pertinent to this <br /> coverage. <br /> F <br /> 5. Termination of this coverage will be effective only upon written notice,sent by certified mail,and only after the <br /> expiration of 60 days after a copy of such written notice is received by the Board and the local enforcement <br /> agency for the jurisdiction in which the facility is located,as evidenced by the return receipts. <br /> From CIWMB 133(11/91) PAGE I OF 2 <br />