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Dec 08 04 10: 56a San Joaquin OES 200-468 2.600 <br /> RECEIVED <br /> COUNTY' OF SAN JOAQUIN DEC - 9 2004 <br /> OFFICr OF EMERGi=NCY SERVICES <br /> ROOill 610,COURTHOUSE SAN JOAQUIN COUNTY <br /> 222 EAST INFHEI:AVENUE OFFICE OF EMERGENCY SEFMCES <br /> STOCETON.CA 95202 <br /> TE11PsonL(z(s)468.3%- <br /> F?AZARU'?lr,hfAtER1AL5 ]A'ISION(<'US�i=uR54fic <br /> 2005 HAZARD JUS NLATERIALS MANAGEMENT PLAN ANl) IN VENTORY <br /> CE)THFICATION S't'ATENII NT <br /> (See Reverse Side fm-Instructions) <br /> 1. Business Idgnt fication Page. Hw:ardous M`uerials Man a_eement Plan. Facility <br /> M�ap(ss))Certi$<adon-Check ont_Ibox only <br /> Ud' 1 certify that there have been no changes to the above listed docurn-ants <br /> since our business's !alit update or chen„ae was suhunitred. <br /> 17 1 certify that there has bean a change to one or more of the above <br /> documents and that appropriate rcvisc:d hartl cap', forms have beet <br /> submitted with this Certification Statement, <br /> 2. CortiEication of Chemical Inventoty-Check.one box IU& <br /> I certify that the infomlation contained in the most recently submitted <br /> chemical inventory is complete, accurate,up-to-c ate, and contaiu5 the <br /> informal ion required by Section 11022 of Title 42 of the United Si aces <br /> Code. I further corLify tha:there has �eeu no oltaage 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 beeb.a change in my chemical inventory sir ce the <br /> last submission and completed hard cupies of changed Chemical <br /> Description Pages with"Add","Delete", or"Revised"marked <br /> appropriately have been submitted wit!a this Certification Statemenr. <br /> I understand that falul or inaccurate information may make my company liable in an <br /> emergency. I further certify that I have(reviewed thc above listed documents and that <br /> the statements checked above constitute an accurate statement. <br /> Business Name aD A RxEL Soff?OES Account# 7 8 2 o <br /> Site Address `Z"1 X23 N ikvs-A I�Cm\9a CA G)S 2z� <br /> Operatori0 xmer � Title <br /> Signature n�q �.c C; _-bate <br />