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>Au N COUNTY OF SAN JOAQUIN <br /> ao. .go` OFFICE OF EMERGENCY SERVICES <br /> ` z 2101 E. Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> } <br /> Telephone:(209)953-6200 <br /> • �'#�i c o a`'�P• Fac:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSI S NAME ADDRESS(Facility Being Inspected <br /> ? 1/ 'fit-(-dGt J�J�� 1r 2 ✓I ��r <br /> ACCOUNT# ART DATE(New Bus5 INSPECrION DATE I ARRIVAL TIME IDEPAler URE TIME INSPVOR�NAME <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&Accurate 7. Presence of Non-Listed Regulated Chemicals <br /> 3.Business HMMP Complete and Accurate / 8. Employees Familiar with HMMP <br /> 4.Chemical Description 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 /> f ✓� �� au ✓ I ( h �� �/ems. <br /> tf('e-c- ct rot.Wd>' of <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 Title) Bu epresen hve Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV 1108 <br />