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SEP 1 12004 <br /> 4,n COUNTY OF SAN JOAQUIN �EadUAl y re UUtiIVly <br /> OFFICE OF EMERGENCY SERVICES aorA ` ER[ NCYSEI!"�r E <br /> ROOM 610.COURTHOUSE DIRECTOR OF <br /> Y: :< <br /> 222 EAST WEBER AVENUE EMERGENCY OPERATIONS <br /> SPOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> 200 HAZARDOUS MATERIALS MANAGEMENT PLAN/INVENTORY <br /> CERTIFICATION STATEMENT <br /> (See Reverse Side for Instructions) <br /> 1 . Business Identification Page HWMP Unstaffed Facility Network Attachment and Facility <br /> MMap - Check one box only <br /> A. ?;L I certify that there have been ng changes to the above listed documents since <br /> our business's last update or change was submitted. <br /> B. I certify that there has been a change to one or more of the above documents <br /> and that either 1)appropriate revised hard copy forms, or 2)Fco File)lete nevi e <br /> electronic copy of our Business ID Page/HMIVIP(H yfNo1P9 <br /> if <br /> appropriate, our Unstaffed Attachments (STAFF97.FP3 File) has/have been <br /> transmitted concurrently with this Certification Statement. <br /> 2. Chemical Inventory (Chemical DescripSLQ4 Page) - Check one box only <br /> A. I certify that the information contained in the most recently submitted chemical <br /> inventory is complete, accurate, up-to-date, and contains the information <br /> required by Section 11022 of Title 42 of the United States Code. I further <br /> certify that there has been no change in the quantity of any hazardous material <br /> reported and that no hazardous materials are being handled that are not listed. <br /> )3. � I certify that there has been a change in our chemical inventory since the last <br /> 1 chemical inventory was submitted and eit 1)completed hard copies of <br /> Chemical Description Pages with "Add","Delete", or"Revised" marked <br /> f appropriately,or 2) a complete revised electronic copy of Our chemical <br /> inventory (CHEM97 File) has been transmitted with this Statement. <br /> 3, �—��ironrtxntal Contact E Mail Address (if available) <br /> I understand that false/inaccurate information may make my company liable in an emergency. I <br /> further certify that I have reviewed the above listed documents and information contained in the <br /> most recently submitted chemical inventory and have ensured that it meets the requirements of <br /> California Health and Safety Code, Chapter 6.95, Article 1. `1 <br /> �1 t .�. OES Account# . <br /> Business Name n J <br /> � <br /> Site Address Lla'f� <br /> II ` <br /> _Title / 11 <br /> �� 1 1 �• i t' I � <br /> i <br /> Facility Operator/Owner_ �r <br /> / I <br /> Date <br /> Signature` ✓t <br />