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COUNTY OF SAN JOAQUIN <br /> Q''•. OFFICE OF EMERGENCY SERVICES RECEIVED <br /> } ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE DEC -5 2003 <br /> ST ON,C9) 95202 Spey E pp y <br /> r ,;. i. x <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 /> ]. Business Identification Page Hazardous Materials Management Plan Facility <br /> Map(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 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 listed documents and that <br /> the statements checked above constitute an accurate statement. a <br /> Business Name M C bffl Id(d5 *2 53 OES Account# I�� <br /> Site Address 115�p l� �J��c im l II U lL1f�aL <br /> Operator/Owner Q ,(� Title Offer <br /> Signature Date <br />