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C COUNTY OF SAN JOAQUIN Ri E(� EIVA..D �• off• OFFICE OF EMERGENCY SERVICES JAN - 9 2004 ROOM 610,COURTHOUSE 1 222 EAST WEBER AVENUE c' I " t STOCKTON,CA 95202 TELEPHONE(209)468-3962 HAZARDOUS MATERIALS DIVISION(209)468-3969 114 - 2004 HAZARDOUS MATERIALS MANAGEMENT PLAN AND INVENTORY CERTIFICATION STATEMENT (See Reverse Side for Instructions) 1. Business Identification Page, Hazardous Materials Management Plan, Facility Map(s) Certification - Check one box only Pj I certify that there have been no changes to the above listed documents since our business's last update or change was submitted. ❑ I certify that there has been a change to one or more of the above documents and that appropriate revised hard copy forms have been submitted with this Certification Statement. 2. Certification of Chemical Inventory - Check one box only K I certify that the information contained in the most recently submitted chemical inventory is complete, accurate, up-to-date, and contains the information required by Section 11022 of Title 42 of the United States Code. I further certify that there has been no change in the quantity of any hazardous material reported and that no hazardous materials are being handled that are not listed. ❑ I certify that there has been a change in my chemical inventory since the last submission and completed hard copies of changed Chemical Description Pages with "Add", "Delete", or"Revised" marked appropriately have been submitted with this Certification Statement. I understand that false or inaccurate information may make my company liable in an emergency. I further certify that I have reviewed the above listed documents and that the statements checked above constitute an accurate statement. Business Name J 4c (c t .) T-IV- ✓l-d� *3 Lt"S OES Account# 9 3(o Z Site Address Lf`) 9 5 S • °I`ice s To C_tc (-a^1 Operator/Owner rpt_ p 6^1k: k 4_ Title t"L!c kz-I t=„r u. Signature Date