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$ % RECEIVED <br /> COUNTY OF SAN JOAQUIN DEC 2 6 2003 <br /> c OFFICE OF EMERGENCY SERVICES S2'VJVAV(pNCO,ilvTy <br /> } ROOM 610,COURTHOUSE EOEENJERGENCYSLr'=.'_ICE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CA 95202 <br /> TELEPHONE(209)468-3962 <br /> 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 /> Mav(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 submirted 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-T4 T ?M(.ICKI t-S C,)�C. OES Account# T /,5 <br /> Site Address i ��ii�3 q co t j H wY 9 9 LO D 110 CA q 524 0 <br /> Operator/Owner ' IAt j 1 A4(t -WD Title MAK A60—L of CCMPL1,gtJC1✓ <br /> Signature �.11J 1rnW11�/ 1� Date 12.'2,3'03 <br />