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Dee 04 2003 10:33SM HF ERJET 3330 <br /> RECEIRIE® <br /> -- COUNTY OF SAN JOAQUIN DEG-! 6­2003 <br /> OFFICE OP EMERGENCY SERVICES �S,9,NJU U? <br /> � • ROOM 63 0,COURTHOUSE Fl61 NCU11P.Ty <br /> `r { 222E•ASTWEBERAVENUE '�E� ,E%LNCI SCP.°ACE <br /> 6 <br /> ._. °•. (� STO('K70N,CA 95202 <br /> TrtrMONE(209)469-3961 <br /> �1 HAZARDOUS MATERIALS DIVISIO14(209)4694969-- - <br /> 2004 HAZARDOUS MATERIALS MANAGEMENT PLAN AND INVENTORY <br /> CERTIFICATION STATEMENT <br /> (See Reverse Side for Instructions) <br /> 1. Dusmess Identification Pae Hazardous Materials Management Plan.Facilit <br /> Map(s)Certification- Check one box only <br /> I e"fy (hat there have"been no changes to the above listed documents <br /> since our business's last update Or change was subtnitted. <br /> ❑ 1 certify that there has been a change to one or more of the above <br /> documents and that appropriate revised hard copy forms have been <br /> submitted with this Certification Statement, <br /> 2. Certification of Chemical Inventory-Check one box only <br /> C 1 certify that the information contained in the most recently submitted <br /> chemical inventory is complete, accurate, up-to-date, and contains the <br /> information required by Section 11022 of Title 42 of the United States <br /> Code. I further certify that there has been no change in the quantity of any <br /> hazardous material reported and that no hazardous materials are being <br /> handled that are not listed. <br /> O 1 certify that there has been a change in my chemical inventory since the <br /> last submission and completed hard copies of changed Chemical <br /> Description Pages with"Add","Delete",or"Revised"marked -- <br /> _ appropriately have beeii'suliriutte3 Willi this Certi tcation Siafeaietit. <br /> I understand thatfalse or inaccurate information may make my company liable In an <br /> emergency. I further certify that I have reviewed the above listed documents and that <br /> the statements checked above constitute an accurate statement. <br /> Business Name <br /> �( ( 'XY% A i7 _OES Account# <br /> Site Address �s� V mayy' EPC$UIEtuL�- ¢ <br /> Operator/Owner r° i l s� d, Title <br /> Signature .$ ,-Date <br /> r <br /> r � <br /> Dec 04 2003 10:33gpt <br /> x330 <br />