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Slate of California California Integrated Waste Management Board <br />CERTIFICATE OF SELF-INSURANCE AND RISK MANAGEMENT <br />1f additional space is needed, add attachment. <br />Operator Operator Address <br />Solid Waste Division <br />San Joaquin County 1810 E. Hazelton Ave., Stockton, CA 95205 <br />Risk Manager Risk Manager Address <br />Canlis Building, Room 106 <br />Richard Pietz 24 S. Hunter St., Stockton, CA 95202 <br />Solid Waste Disposal Facilities Covered (Enter Information for Each Facility) LIMITS OF LIABILITY <br />FRecycling <br />Address Facility Information Per Occurrence' Annual Aggregate' <br />Number <br />unty 17720 E. <br />Center Harney Lane $ 1,000,000 <br />andfill Lodi, CA 39-�-0022 $ 1,000,000 <br />Corral Hollow 31130 S. Corral <br />Sanitary Landfill Hollow Rd. 39 -AA -005 $ 1,000,000 $ 1,000,000 <br />Tracy, CA <br />Foothill Sanitary 6484 N. Waverly <br />Landfill Rd. 39 -AA -0004 $ 1,000,000 $ 1,000,000 <br />-------------- <br />Linden, CA <br />Harney Lane 147.50 E <br />Sanitary Landfill Harney Lane 39 -AA -0003 $ 1 000,000 $ 1,000,000 <br />Lodi, CA <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 third <br />party bodily injury and property damage in connection with the operator's obligation to demonstrate financial responsibility under <br />Title 27, California Code of Regulations, Division 2, Subdivision 1, Chapter 6- The coverage applies to the above -listed facility(ies) <br />for accidental occurrences arising from the operations of the factity(tes). <br />2. The limits of liability are the amounts stated above for "per occurrence" and "annual aggregate", exclusive of legal <br />defense costs. <br />3 Indicate whether this coverage is primary. <br />4- Upon request by the California Integrated Waste Management Board (CIWMB), the operator agrees to furnish to the <br />CIWMB any documents pertinent to this coverage. <br />5 Termination of this coverage, will be effective only upon written notice, sent by certified mail, and only afler the <br />expiration of 60 days after a copy of such written notice is received by the CIWMB, as evidenced by the return receipt <br />CIWMB109 (12101) Page 1 of 2 <br />