HomeMy WebLinkAboutBUSINESS PLAN 11/19/2001
Operate
Waste Unified Permit
it to
Materials/Hazardous
Per
Hazardous
CONDITIONS OF.PERM,IT ON REVERSE SIDE
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ItI Hazardous Materials Plan
o Underground Storage of Hazardous Materials
o Risk Management Program
o Hazardous Waste On-Site Treatment
Permit ID #: 015-000-001805
H & H PARTS WAREHOUSE ,\
lOCATION: 4306 WIBLE RD AÆ'~' '
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Bakersfield Fire Department
OFFICE OF ENVIRONMENTAL SER VICES
1715 Chester Ave., 3rd Floor
Bakersfield, CA 93301
Voice (661) 326-3979
'FAX (661) 326-0576
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Issued by:
Per it to Operftte
Hazardous Materials/Hazardous Waste Unified Permit
CONDITIONS OF PERMIT ON REVERSE SIDE
,
This permit is issued for the following:
ardous Materials Plan
e,r$Jround Storage of Hazardous Materials
PERMIT ID# 01S-Q21.Q0180S mtQ~gement Program
H & H PARTS WAREHOUSE mmm Waste
LOCATION 4306 WIBLE
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Issued by:
Bakersfield Fire Department Approved by: _ -
OFFICE OF ENVIRONMENTAL SER VICES -
1715 Chester Ave., 3rd Floor
Bakersfield. CA 93301
Voice (805) 326-3979 Expiration Date: 0
FAX (805) 326-0576
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H & H PARTS WAREHOUSE
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4306 WIBLE RD #A ti
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UNIFIED PROGRAM INSPECTION CHECKLIST~°
SECTION 1: business Plan ane! Inventory Program
BAKERSFIELD FIRE DEPT
H apt D Prevention Services
~~tl 900 Truxtun Ave., Suite 210
~Rrr r Bakersfield, CA 93301
Tel.: (661) 326-3979
_ Fax: (661) 872-2171
FACILITY NAME INSPECTION DATE INSPECTION TIME
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ADDRESS HONE NO. O OF EMPLOYEES
FACIL TY CONTACT
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Section 1: Business Plan and Inventory Program (~~q
ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION
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V=Violation ~'NT
DEC 18 2006 COMMENTS
~1 ^ APPROPRIATE PERMIT ON HAND
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~ ^ VISIBLE ADDRESS
^ CORRECT OCCUPANCY I
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^ VERIFICATION OF INVENTORY MATERIALS
^ VERIFICATION OF QUANTITIES
^ VERIFICATION OF LOCATION
~ ^ PROPER SEGREGATION OF MATERIAL
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1 ` VERIFICATION OF MSDS AVAILABILITY
^ VERIFICATION OF HAZ MAT TRAINING
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^ VERIFICATION OF ABATEMENT SUPPLIES AND
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^ EMERGENCY PROCEDURES ADEQUATE
^ CONTAINERS PROPERLY LABELED
^ HOUSEKEEPING
^ FIRE PROTECTION
-^ SITE DIAGRAM ADEQUATE & ON HAND
ANY HAZARDOUS WASTE ON SITE? ^ YES NO
EXPLAIN: ~ _..
.QUESTIONS REGARDING11THIS INSPECTION? PLEASE CALL US AT (661) 326-3979
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Inspector (Please Print) Fire Prevention / ts' In /Shift of Site/Station #
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SITE DIAGRAM r 1 FACll..ITY DIAGRAM ~
Business Name: H & H Parts Warehouse .
Business Address: 4306 Wible Road Suite A Bakersfield, Ca. 93313
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UNIFIED ~PROGRAIVI INSPECTION CFiECI(LIST
SECTION 1: Business Plan and Inventory Program ~ Tel.: (661) 32s-3979
Fax: (661) 872-2171
FACILITY NAME INSPECTION DATE INSPECTION TIME
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ADDRESS I I d
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FACILITY CONTACT USINESS ID NUMBER
15-021- OO~~C~S"
Section 1: Business Plan and Inventory Program ®~'~
ROUTINE ^ COMBINED ^ JOINT AGENCY ^ MULTI-AGENCY ^ COMPLAINT ^ RE-INSPECTION ~
M
C V ~ C=Compliance OPERATION
V=Violation COMMENTS
^ APPROPRIATE PERMIT ON HAND
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BUSIrIBSS PLAN CONTACT INFORMATION ACCURATE ,%Gwr-arzse-ky Gc., ~ Q..i~ ° - - ~ b Y - ~+ `X13 u3
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^ VISIBLE ADDRESS
^ CORRECT OCCUPANCY
^ VERIFICATION OF INVENTORY MATERIALS
^ VERIFICATION OF QUANTITIES
^ VERIFICATION OF LOCATION
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^ PROPER SEGREGATION OF MATERIAL I
^ VERIFICATION OF MSDS AVAILABILITY
^ VERIFICATION OF HAZ MAT TRAINING
^ VERIFICATION OF ABATEMENT SUPPLIES AND
PROCEDURES
^ EMERGENCY PROCEDURES ADEQUATE
^ CONTAINERS PROPERLY LABELED ~
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^ HOUSEKEEPING j
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^ FIRE PROTECTION
^ SITE DIAGRAM ADEQUATE & ON HAND
ANY HAZARDOUS WASTE ON SITE?
EXPLAIN:
QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT (661) 326-3979
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Inspector (Please Print) Fire revention / 1" In /Shift of Site/Station ff
White -Prevention Services Yellow -Station Copy Pink -Business Copy
^ YES ®NO
BAKERSFIELD FIRE DEPT
B , p , D Prevention Services
fitww ~ ~ 900 Truxtun Ave., Suite 210
awry r Bakersfield, CA 93301
FD2049 (Rev. 02/05)
UNIFIED PROGRAM INSPECTION CHECKLIST
SECTION 1 Business Plan and Inventory Program
~-
Bakersfield Fire Dept.
Enironmental Services
1715 Chester Ave
Bakersfield, CA 93301
Tel: 1661126=~U7U
FACILITY NAME ~ INSPECTION DATE 'INSPECTION TIME
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ADDRESS
3 PHONE No.
-- ~-~ ~-~~' ~~ ~ ~ , ~ ,L~Q I rNo. of Employees --~
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F.4CIUTYCONTACT ~ ~-------------- IBu~ Number~~------------- ---
:A-M.~ S NOO K ~ ~ ~V I 15-021- Q'jl
Section 1: Business Plan and Inventory Program
Routine ^ Combined ^ Joint Agency ^Mnlti-Agency ^ Complaint ^ Re-inspection
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V \V=Voatonn~l OPERATION ~ COMMENTS
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LY ^ APPROPRIATE PERMIT ON HAND ___ _ - I
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L'~ ^ BUSINESS PLAN CONTACT INFORMATION ACCURATE - ---- -- -
^ VISIBLE ADDRESS
^ CORRECT OCCUPANCY
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^ VERIFICATION OF INVENTORY MATERIALS
LV' ^ VERIFICATION OF QUANTITIES
^ VERIFICATION OF LOCATION
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PROPER SEGREGATION OF MATERIAL
1Q ^ VERIFICATION OF MSDS AVAILABILITYE
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^ VERIFICATION OF I"IAT MAT TRAINING ___._.
~^ VERIFICATION OF ABATEMENT SUPPLIES AND PROCEDURES
~^ EMERGENCY PROCEDURES ADEQUATE
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LrY ^ CONTAINERS PROPERLY LABELED ----- ------------
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L'1 ^ FIRE PROTECTION
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SITE DIAGRAM ADEQUATE 8c ON HAND
ANY HAZARDOUS WASTE ON SITE?: ^ YES Ird NO
EXPLAIN:
QUESTIONS REGARDING THIS INSPECTION? PLEASE CALL US AT ~F)F)') ~ 326-3979
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Inspector Badge No.
White -Environmental Services Yellow • Station Copy
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Pink • Business Copy
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H & H PARTS WAREHOUSE
SiteID: 015-021-001805
Manager :
Location: 4306 WIBLE RD A
City BAKERSFIELD
CommCode: BAKERSFIELD STATION 07
EPA Numb:
BusPhone:
Map : 123
Grid: 13C
(805) 396-8649
CommHaz : Moderate
FacUnits: 1 AOV:
SIC Code:5013
DunnBrad:77-0138-407
Emergency Contact
JAMES HOOKER
Business Phone:
24-Hour Phone
Pager Phone
/ Title
/ CO-OWNER
(805) 396-8649x
(805) 765-7735x
() x
Emergency Contact
JIM HOOKER
Business Phone:
24-Hour Phone
Pager Phone
/ Title
/ CO-OWNER
(805) 765-2438x
(805) 765-7459x
() x
Period
Pre parer:
Certif'd:
to
Fire ImmHlth
Phone: (805) 765-7735x
State: CA
Zip 93268
Phone: (805) 765-7735x
State: CA
Zip 93268
TotalASTs: = Gal
TotalUSTs: = Gal
RSs: Yes
Hazmat Hazards: RSs
Contact :
MailAddr: PO BOX 726
City TAFT
Owner
Address
City
JAMES & JIM HOOKER
PO BOX 726
TAFT
1997.
¡tJ~ ~' 3-/6-6/1
f= Hazmat Inventory
f== Alphabetical Order
One Unified List ì
All Materials at Site ì
IspecHazEPA Hazards Frm I DailyMax IUnitlMCP
F IH S 120.00 GAL Hi
Hazmat Common Name. . .
BATTERIES
I, \Yo. 1M. D (.' Ll 1'0("1 k ~ v 1D0 hereby certify ~hat I ha\'s
~
reviewed ~he attached hazardous materials manageo
ment plan for l-1 {< U- j)", .. L< t,Jh~d that it along with
~
any corrections constitute a complete and correct man-
agement plan for i'Ry facility.
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'<to ~.~
11- ,Lq-o/
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10/23/2001
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F H & H PARTS WAREHOUSE
p= Inventory Item 0001
== COMMON NAME / CHEMICAL NAME
BATTERIES
AUTOMOTIVE BATTERIES (BATTERY ACID)
Location within this Facility Unit
NORTH WALL
SiteID: 015-021-001805 ì
Facility Unit: Fixed Containers at Site ì
Days On Site
365
Map: Grid:
CAS#
7664-93-9
STATE - TYPE
Solid Mixture
PRESSURE
Ambient
TEMPERATURE
Ambient
CONTAINER TYPE
PLASTIC CONTAINER
Largest Container
1.00 GAL
AMOUNTS AT THIS LOCATION
Daily Maximum
120.00 GAL
Daily Average
85.00 GAL
HAZA U EN
%Wt. RS CAS#
.....
37.00 Battery Acid No 7664939
RDO S COMPON TS
HAZARD ASSESSMENTS
TSecret RS BioHaz Radioactive/Amount EPA Hazards NFPA USDOT# MCP
No Yes No No/ Curies F IH / / / Hi
-2- 10/23/2001
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SiteID: 015-021-001805 9
Fast Format 9
Overall Site 9
10/07/1997 1
10/07/1997
F H & H PARTS WAREHOUSE
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f= Notif./Evacuation/Medical
~ Agency Notification
LALL FIRE DEPT.
Public Notif./Evacuation
10/07/1997
Employee Notif./Evacuation
VERBAL.
NOTIFY SURROUNDING BUSINESSES.
Emergency Medical Plan
10/07/1997
USE BASIC FIRST AID AND CALL 911.
-3-
10/23/2001
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SiteID: 015-021-001805 9
Fast Format ì
Overall Site 9
10/07/1997
F H & H PARTS WAREHOUSE
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f= Mitigation/Prevent/Abatemt
Release Prevention
THEY ARE STORED ON SHELVES AND ON SHIPPING PALLETS. WE CHECK DAILY FOR
PROBLEMS.
Release Containment 10/07/1997
THEY COME IN FACTORY SEALED CONTAINERS. USED OR DAMAGED BATTERIES ARE
STORED IN MANUFACTURES SUPPLIED CONTAINERS AND ARE RETURNED TO MANUFACTURES.
Clean Up
10/07/1997
BASIC CLEAN UP AS DESCRIBED IN MSDS.
Other Resource Activation
-4-
10/23/2001
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SiteID: 015-021-001805 ì
Fast Format ì
Overall Site ì
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F H & H PARTS WAREHOUSE
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f= Site Emergency Factors
r== Special Hazards
Utility Shut-Offs
10/07/1997
A) GAS - NONE
B) ELECTRICAL - SW SIDE OF BLDG
C) WATER -
D) SPECIAL - NONE
E) LOCK BOX - NO
Fire Protec./Avail. Water
10/07/1997
PRIVATE FIRE PROTECTION - FACILITY HAS SPRINKLER SYSTEM.
NEAREST FIRE HYDRANT - LOCATED ON SW OUTER CORNER OF BLDG.
Building Occupancy Level
-5-
10/23/2001
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F H & H PARTS WAREHOUSE
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F Training
Employee Training
SiteID: 015-021-001805 ì
Fast .Format 9
Overall Site 9
10/07/1997
WE HAVE 3 EMPLOYEES AT THIS FACILITY.
WE DO HAVE MSDS SHEETS ON FILE.
BRIEF SUMMARY OF TRAINING PROGRAM: EMPLOYEE MEETING ONCE A MONTH TO REVIEW
SAFETY PROCEDURES.
Page 2
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Held for Future Use
Held for Future Use
-6-
10/23/2001
"ACDelêo
H & H Parts Warehouse
(800) 826-1075
AC/Delco Connection
James Hooker
(805) 765-2437
218 Harrison St.
Taft, CA 93268
(805) 396-8649
4306 Wible Rd. "C"
Bakersfield, CA 93313
November 7,2001
Attn. Director, Office of Environmental Services:
This letter is in regards to the notice sent October 25, 2001. It is to
notify you of the location and the number of old batteries stored in our
location. The batteries are stored in the North East comer of the building.
There could be approximately up to 66 batteries stored at one time which
is one pallet full. If you need any further infonnation please call us and we
will help- in any way we can.
Thank you,
~~
H & H Parts Whse.
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CITY OF BAKERSFIEI"D FIRE DEPARTMENT
OFFICE OF ENVIRONMENTAL SERVICES
UNIFIED PROGRAM INSPECTION CHECKLIST
1715 Chester Ave., 3rd F'loor, Bakersfield, CA 93301
3
FACILITY NAME 14~b-J '~,..+ lð~"efu.bt--'SL-·
ADDRESS L{ 3 ð Cë cJ ,. hi €. f2o.{
FACILITY CONTACT (fltUA-"" ~J'-~v'
INSPECTION TIME dO V\A.; '-"
INSPECTION DATE 10- 10- 0 {
PHONE NO. ~ 'b - fl,cf cr
BUSINESS ID NO. 15-210- (!) 0 I i"o s-
NUMBER OF EMPLOYEES -z,.
Section 1:
~outine
Business Plan and Inventory Program
D Combined
D Joint .Agency
o Multi-Agency
o Complaint
ORe-inspection
OPERATION C V COMMENTS
Appropriate penn it on hand V
Business plan contact infonnation accurate ./ 5ee c.kú. ~P<:'
Visible address Iv' a
Correct occupancy Iv'
Verification of inventory materials V
Verification of quantities ,/
Verification of location ./
Proper segregation of material ¡/
Verification of MSDS availability ,/
Verification of Haz Mat training ,/
Verification of abatement supplies and procedures IV"V
Emergency procedures adequate r/
Containers properly labeled ¡/
Housekeeping ,/
Fire Protection 1/
Site Diagram Adequate & On Hand (...;
C=Compliance
V=Violation
Any hazardous was.tt on site?:
Explain: ð leV ~.a<; p ,.. a (' 5
6'Yes DNo
White - Env, Svcs.
Yellow· Station Copy
Pink· Business Copy
Business /~espo
Inspecto :
Questions regarding this inspection? Please call us at (661) 326-3979
//
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CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (805) 326-3979,nJ'
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INSTRUCTIONS: l!2~~
1. To avoid further action, return this form within 30 days of receipt. ~ ~ ~lo ( lqq l
2. TYPE/PRINT ANSWERS IN ENGLISH. G
3. Answer the questions below for the business as a whole.
4. Be as briefand concise as possible.
SECTION 1: BUSINESS IDENTIFICATION DATA
BUSINESS NAME:
H R, H P;:¡rt-~ W;:¡rph011~p
LOCATION:
4306 Wible Road Suite A Bakersfield, Ca. 93313
MAILING ADDRESS: P_ o. Box 726 Taft. Ca_ 93268
CITY:
STATE:
ZIP:
PHONE: ( 805) 396-8649
DUN & BRADSTREET NUMBER:
77-0138407
SIC CODE: r; 0 1 1
PRIMARY ACTIVITY: Sellin9 Auto Parts
O~R: James Hooker
MAILING ADDRESS: P. O. Box 726
Taft. Ca. 93268
SECTION 2: EMERGENCY NOTIFICATION
CONTACT TITLE BUS. PHONE 24 HR. PHONE
1. ,T;:¡mp~ Hookpr Co-Owner (850)396-8649 (805)765-7711:)
2. Jim Hooker Co-Owner (805)7652438 (805)765-7459
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HAZARDOUS MATEmALS MANAGEMENT PLAN
SECTION 3: TRAINING
NUMBER OF EMPLOYEES: 3
MATERIAL SAFETY DATA SHEETS ON FILE: YES
BRIEF SUMMARY OF TRAINING PROGRAM: Employee meeting once a month,
to reveiw safety procedures.
SECTION 4: EXEMPTION REOlÆST
I CERTIFY UNDER PENALTY OF PERJURY THAT MY BUSINESS IS EXEMPT FROM
THE REPORTING REQUIREMENTS OF CHAPTER 6.95 OF THE "CALIFORNIA HEALTH
& SAFETY CODE" FOR THE FOLLOWING REASONS:
WE DO NOT HANDLE HAZARDOUS MATERIALS.
WE DO HANDLE HAZARDOUS MATERIALS, BUT THE QUANTITIES AT
NO TIME EXCEED THE MINIMUM REPORTING QUANTITIES.
OTHER (SPECIFY REASON)
SECTION 5: CERTIFICATION
I, James Hooker CERTIFY THAT THE ABOVE
INFORMATION IS ACCURATE. I UNDERSTAND THAT TInS INFORMATION WILL BE
USED TO FULFILL MY FIRM'S OBLIGATIONS UNDER THE "CALIFORNIA HEALTH
AND SAFETY CODE" ON HAZARDOUS MATERIALS (DIY. 20 CHAPTER 6.95 SEC. 25500
ET AL.) AND THAT INACCURATE INFORMATION CONSTITUTES PERJURY.
Co-Owner
SIGNATURE
TITLE
September 23,1997
DATE
2
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HAZARDOUSMATEmALSMANAGEMENTPLAN
SECTION 6: NOTIFICATION AND EVACUATION PROCEDURES
A. AGENCY NOTIFICATION PROCEDURES: Call Fire Department
B. EMPLOYEE NOTIFICATION AND EVACUATION: Verbal
C.
PUBLIC EVACUATION:
Notify Surrounding Businesses
D. EMERGENCY MEDICAL PLAN: Use basic First Aid and call 911.
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HAZARDOUSMATE~SMANAGEMENTPLAN
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SECTION 7: MITIGATION. PREVENTION AND ABATEMENT PLAN
A. RELEASE PREVENTION STEPS: They are stored on shelves and on
shipping pallets. We check daily for problems.
B. RELEASE CONTAINMENT AND/OR MINIMIZATION: They come in factory
sealed containers. Used or damaged batteries are stored in
manufactures supplied containers and are returned to manufactures.
C. CLEAN-UP PROCEDURES: Basic clean up as described in MSDS.
SECTION 8: UTILITY SHUT -OFFS (LOCATION OF SHUT -OFFS AT YOUR FACILITY)
NATURAL GAS/PROP ANE: None
ELECTRICAL:
WATER:
SPECIAL:
LOCK BOX: YES/NO
Southwest side of building
IF YES, LOCATION:
SECTION 9: PRIVATE FIRE PROTECTION/W ATER AVAILABILITY
A. PRIVATE FIRE PROTECTION: Facility has sprinkler system
B. WATER AVAILABILITY (FIRE HYDRANT): Located on southwest outer
corner of building,
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CITY OF BAKERSFIELD
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester Ave., Bakersfield, CA (805) 326-3979
HAZARDOUSMATERlALSINVENTORY
FACILITY DESCRIPTION
CHECK IF BUSINESS IS A FARM [ ]
BUSINESS NAME H & H Parts Warehouse
FACILITY NAME H & H Parts Warehouse
SITE ADDRESS 430€) Wiblo RO.:::ld Suite A.
CITY Bakersfield
STATE Ca.
ZIP 93313
NATURE OF BUSINESS
Automotive Parts Sales
SIC CODE
5013
DUN & BRADSTREET NUMBER 77 - 0 1 38407
OWNER/OPERATOR James Hooker
PHONE (805)765-7735
MAILING ADDRESS P.O. Box 726
CITY
Taft,
STATE Ca.
ZIP 93268
EMERGENCY CONTACTS
NAME ,Trlmpe::.J Hnnk~r
TITLE Co-Owner
BUSINESS PHONE (805) 396-8649
24 HOUR PHONE (805) 765-7735
NAME James D. Hooker
TITLE Co-Owner
BUSINESS PHONE (805) 765-2437
24 HOUR PHONE (805) 765 - 7 4 5 9
1
&ARDOUS MATERIALS INVENTty
"!i.~~..'?~"
Business Name H&H Parts Whse.
Page...L of...L
Adœress4306 Wible Rd. Suite A Bakersfield
CHEMICAL DESCRIPTION
I) INVENTORY STATUS: New rx] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [X] Trade Secret [
2) Common Name: Aut.omotive Batteries
3) DOT # (optional)
Chemical Name: Battery Acid
ARM [ ] CAS #
4) Physical & Health
Hazard Categories
PHYSICAL HEALTII
Fire [X] Reactive [ ] Sudden Release of Pressure [ ] hnmediate Health (Acute) [X] Delayed Health (Chronic) [
5) WASTE CLASSIFICATION 111
(3-digit code trom DHS Fonn 8022)
USE CODE
47
6) PHYSICAL ST A 1E
Solid [ ] Liquid pc] Gas [ ]
Pure [
Mixture [X ] Waste [ ] Radioactive [
8) STORAGE CODES
a) Container: 1 n
b) Pressure: 1
c ) Temperature 1
7) AMOUNT AND TIME AT FACILITY
Maximwn Daily Amount 1? n C) ç¡l
Average Daily Amount 85 g à 1
Annual Amount 1 0 0 0 <J .:11
Largest Size Container 1 <J .:11
# Days on Site J G ~
UNITS OF MEASURE
Lbs[ ] Gal [X] ft3[
Ctuies [ ]
Circle Which Months:
All Year, J, F, M, A. M, J, J, A. S, 0, N, D
9)~: Li~
the three most hazardous
chemical components or
any ARM components
COMPONENf
1) sulfur] c Acid
2) water
3) Load
CAS#
007664939
0077)?185
0071J9921
%WT
37%
"RÇllÇ!n('~
ARM
[ ]
[ ]
[ ]
lO)LOCATION
North Wall
1) INVENTORY STATUS: New [ ] Addition [ ] Revision [ ] Deletion [ ] Check if chemical is a NON Trade Secret [ ] Trade Secret[ ]
2) Common Name:
3) DOT # (optional)
Chemical Name:
ARM [ ] CAS#
4) Physical & Health
Hazard Categories
PHYSICAL HEAL TII
Fire [ ] Reactive [ ] Sudden Release of Pressure [ ] hnmediate Health (Acute) [ ] Delayed Health (Chronic) [
5) WASTE CLASSIFICATION
(3-digit code trom DHS Fonn 8022)
USE CODE
6) PHYSICAL STATE
Solid [
Liquid [
Gas [ ]
Pure [
Mixture [ ] Waste [ ] Radioactive [
7) AMOUNT AND TIME AT FACILITY
Maximwn Daily Amount
Average Daily Amount
Annual Amount
Largest Size Container
# Days on Site
UNITS OF MEASURE
Lbs [ ] Gal [ ] ft3 [
Ctuies [ ]
8) STORAGE CODES
a) Container:
b) Pressure:
c ) Temperature
Circle Which Months:
All Year, J, F, M, A, M, J, J, A, S, 0, N, D
9)~: List
thethreemo~hazardo~ 1)
chemical components or 2)
any AHM components 3)
COMPONENf
CAS#
%WT
ARM
[ ]
[ ]
[ ]
IO)LOCATION
I certifY under penalty of law, that I have personally examined and am familiar with the infonnation on this and all attached docwnents. I
believe the submitted infonnation is true, accurate and complete.
PRINT Name & Title of Authorized Company Representative
Signature
Date