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1800 North California Street PR0231036 <br /> September 27, 2021 Program: UST <br /> PHOTO 3: Current certification of financial responsibility not uploaded to CERS. <br /> State WResources Control Boartl For Stale ilea only <br /> ter <br /> Division of Financial Assistance <br /> P.O.Box 944212 <br /> Sacramento,CA 94244-2121 <br /> (Inswaians on reve a side) <br /> CERTIFICATION OF FINANCIAL RESPONSIBILITY <br /> FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM <br /> A. 1 am required to demonstrat Financial Responsibility in the requlretl amount as specified in California Cade of Regulations(CCR),TNe 23, <br /> DiNsion 3,Chapter 18,Section 2807, <br /> 500,000 dollars per occunan- 1 million dollars annual aggregate <br /> 99re9a <br /> or AND or <br /> 1 million dollars per occurrenoe 2 million dollars annual aggregate <br /> n <br /> ggrega <br /> O <br /> is. St Josephs Medical Center <br /> (Name or Tank hereby certifies that it is in compliance with the requirements of Section 2807, y <br /> California Code o";gutabonsOwrreror0,Title 23,Division 3,Chapter 18,Article 3,Section 2807. <br /> The mechanisms used to demonstrate financial res nsibil as n <br /> po r(y required by Section 2807 are as follows: <br /> C.Mechanism <br /> T eMechanism Coverage Coverage Corrective third Party <br /> Name and Adtlress of Issuer Number Amount Period Action Com <br /> Financial CommonSpint Health N/A $1,000,000 12/1/2020 Yes Yes <br /> Guarantee to <br /> 12/1/2021 <br /> Note: <br /> Note:/f you are using the State Fund as any part of your demonstration of financial responsibility,your execution and submission of <br /> this certification also certifies that you are in compliance and shall maintain compliance with all conditions for participation in the <br /> Fund See instructions. <br /> D. Facility Name Facility Address <br /> St Josephs Medical Center 1800 N California Street,Stockton,CA 95204 <br /> Facility Name Facility Address <br /> Facility Name Facility Address <br /> E. Sign tura of T n wn r or perator Date Name and Title of Tank Owner or Operator <br /> 011/70 Donald J. Wiley, President & CEO <br /> ignture of Witness or No ary r Date Name of Witness or Notary <br /> b) �JII2P Diane Bertilacchi <br /> ;FR(Revised 11/08) FILE:Original-Local Agency Copies-Facility/Site(s) <br /> Lydia Baker, SR. REHS Page 3 of 22 <br />