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State of California California Integrated Waste Management Board <br /> CERTIFICATE OF SELF-INSURANCE AND RISK MANAGEMENT <br /> (If 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 /> Name Address Facility Information Per Occurrence* Annual Aggregate* <br /> Number <br /> North County 17720 E. <br /> Recycling Center Harney Lane 39-AA-0022 $ 1,000,000 $ 1,000,000 <br /> & Sanitary Landfill Lodi, CA <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 /> Linden, CA <br /> Harney Lane 14750 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 <br /> OTAL :$ 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 facility(ies). <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 after 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 /> CIVVMB109(12101) Page 1 of 2 <br />