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COUNTY OF SAN JOAQUIN <br /> i° a�oo OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> • =-_ Telephone: (209)953-6200 <br /> •.�.,. �i• Fax:(209)953-6268 <br /> arc°ex HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUS ESS NAME I ADDRESS(Favi 'ty Being Inspected) <br /> ACCOUNT# START DATE(New Bis) INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> au8 / ! - a� --to r ce 16- c 10vartill <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible 6. Facility Map Complete and Accurate <br /> 2.Business Identification Page Complete 8t.Accurate 7. Presence of Non-Listed Regulated Chemicals <br /> 3.Business HMMP Complete and Accurate 8. Employees Familiar with HMMP <br /> 4.Chemical Descriptiou Pages Complete and Accurate . 9. Hazardous Materials/Waste Properly Labelled <br /> 5.Training Records Available 10. Conditions that would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> QIA, de0 1l <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: / Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Tide) Business Representative(Signature) <br /> VMI1 ' Vi n 0 —�—q, ES <br /> PINK CCOPY: US <br /> M lA PINK COPY: BUSINESS <br /> aev Ivey <br />