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COUNTY OF SAN JOAQUIND <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE JAN - 9 2004 <br /> d 222 EAST WEBER AVENUE <br /> STOCKTON,CA 95202FFrL, °DilALif."N(r Iy <br /> TELEPHONE(209)468-3962 .LJ•rliER6£id0/jZ^!ry�E <br /> s .,,�' HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> 2004 HAZARDOUS MATERIALS MANAGEMENT PLAN AND INVENTORY <br /> CERTIFICATION STATEMENT <br /> (See Reverse Side for Instructions) <br /> 1. Business Identification Page, Hazardous Materials Management Plan, Facility <br /> MaD(s) Certification - Check one box only <br /> ❑ I certify that there have been no changes to the above listed documents <br /> since our business's last update or change was submitted. <br /> ® I 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 /> %] I 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 /> ❑ I 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 been submitted with this Certification Statement. <br /> I understand that false 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 J Rc-K (,j rw6 aa-)c * 53' OES Account# 9 ZS3 <br /> Site Address 2 '�/ 2— M/+4—C u L t .✓E S T-C)C_�Ta-'J <br /> Operator/OTitle M�� E c ✓� <br /> Signature Date /e./o <br />