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,�L� V OIEQ ViN. <br /> O <br /> OFFICE F EMERGENCY SERVICES' <br /> R001v-610,Co> RTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STQ�CTON'A 95202. oaGtua1 • G!F <br /> .: <br /> TELEPHONE(209)46$-3962 - SSGO ES C- <br /> ! HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> 2004 HAZARDOUS MATERIALS MANAdEENT FLAN AND INVENTORY <br /> CERTIFICATION STATEMENT <br /> (See Reverse Side for instructions) <br /> 1. Business Identification Pae Hazardous Materials Mana einem Plan Facili <br /> tv <br /> Mans) 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 beena change to one <br /> ® g 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 I---- to Check one box onl <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 m change in <br /> g y 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 fisted documents and that <br /> the statements checked above constitute an accurate statement. <br /> R, <br /> Business Name . <br /> _U1JI0 CoR-PoP. t'►o�J OES Account# CS;S'Z <br /> Site Address ., <br /> 1_a CSA- 44, g- <br /> Operator/Owner Title Q }'t- Yylt <br /> Signature ' Datel $ J o H <br />