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RECEIVED <br /> HP 1 S 2001 <br /> SAN JUAUUIN COUNTY <br /> OFFICE OF EMERGENCY SLRVICE: <br /> t.l}tft i 6i- a"- Ti til 92d{S T <br /> c <br /> VYFa('E �S' i'nicR+.sEia., r <br /> x1 xvi7ivi otv.Cvvne ljtiiSE fir,;;-i:a, '` ' <br /> c'rrv_"itXONT CA 9520' <br /> ?F?.E?Iidtv'E <br /> MW 458-346, <br /> ,�. HAZHRWUS MATERIALS DivisiON(209)"9-1969 <br /> 2004 tiro <br /> "Z.Attyd)1tiSRiA[`f�iciAF.$PvL�T'tAva`.t'`e€1:"�$"-w`.'� ag�+,ajan;lv'�•::::�' <br /> CKWfIrtC;ATION STATEMENT <br /> (See Reverse Side for Instructions) <br /> t. Business identit caiiun i ag %:v` :utas ` nt I'1 an <br /> Ma (sl Cetyiica0on-4 neck one uoz only <br /> QI 1 certify that there have been no changes to the above listed documents <br /> g'µ:e- our b•ssunRzs•s last lTpdatr.9r change was submitted. <br /> G 1 certify that there has iueca a change to one of morc of the abovit <br /> documents and that appropriate revised hard copy ;ours have been <br /> submitted with this Certit-acatiotl Statement. <br /> t.clii ..catiex:o f-h=iral Inventory - Check one box only . <br /> 1 certify that the intbrinn'ailon contained in L.11L'most recenils'S::L=:rutted <br /> chemical inventory is complete, accurate,ufi-SG-dale, ani; {mtaiim`1R <br /> information required by Section 11022 o(Title 42 of the Umied States- <br /> Code. <br /> tatesCode. I further certify that there has been no change in ttie quantity of any <br /> hazardous material reported and that no hazardous materials are being <br /> handled tb tt cre not listed. i <br /> Ej 1 certify that there hag been a citarigo in i3'ij ch2,iiCwl ii.:'C-utSl.^.:= 111 <br /> i,y.. rlsneeli++^e%l32L"i•! <br /> iasi jUbTFiiSSivu w^,..CCm1lt�ted vaP'4 COjii?5 or� --_ - <br /> ` ITeSCLiDL1en J'aPCS 4Yitl1 "� �',`•i:�.t.': ", i:r"r.,,..oc..'r;arced <br /> (�, b?-vv s5-'iPv Tei' AILC' - sze_ Tsai <br /> 3:eT�=-rta Y.r3 !Ev gt€ •r <br /> i us.tetn,........ --. <br /> res.bi. L 4. a.n.rioarc. the above listed documents and thief <br /> emergency. I fui`thca cea%sag c.zt --L'- - - ", <br /> the stiatements checked above constitute an accurate statement. <br /> Business Name re zf �.—UES Account# <br /> Site Address <br /> 19L K a art, <br /> Q <br /> o�� / <br /> Operator/Ownerok f ss o e r s Title .�a^7 n o'er <br /> Signature <br /> r � Date <br /> G= V """' <br /> Q3 ;_4 <br /> 4 <br /> i <br /> t <br /> 88 39tld SNTA 83%M 0IZOLZL 90:88 L00Z/ETIEO <br />