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COUNTY OF SAN JOAQUIN <br /> �.•�a'.o <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> i=o'nNs • Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> ACCOUNT fSTART DATE(New BuINSP-ECTION DA1TE 3 (fe _.or afac <br /> -U" 0OE� E INSPEOR N4ME <br /> DEPARTUR <br /> (2s, 5 ✓'c s <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible —TFacility 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 /> tj­ Ie( I A I/'L <br /> L,s,ness <br /> ;Actions <br /> OLLOW UP INFORMATION <br /> /� Additional <br /> d By: "(— '� Referrals/Notes: <br /> EMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Representative(Print Name and Title) Bus,gess Represent I (Signature) <br /> /`, r� h J/J WHITE COPY: OES <br /> 7 /'( PINK COPY: BUSINESS <br /> REV 12M8 <br />