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a COUNTY OF SAN JOAQUIN <br /> ,. OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> •.� -,. . :p• Fax:(209)953-6268 <br /> �/FC'R� HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME pp ADDRESS(F ility Being Ins cted) <br /> 4-c.. 1 P07 Atic _rlo CIL9S_zu <br /> ACCqkWT# START <br /> �DATE(New Bus) INS ION ATE ARRIVAL TIME DEPARTURE TIME I SSP OR NA E <br /> Ille4 <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Acs le 6. Facility Map Complete and Accurate <br /> 2.Business Identification Page C plete&Accurate 7. Presence of Non-Listed RegulatedPV6micals <br /> 3.Business HMMP Com a and Accurate 8. Employees Familiar with P <br /> 4.Chemicalptiou Pages Complete and Accurate 9. Hazardous Materi aste Properly Labelled <br /> 5.Training Records Available 10. Conditions t would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS// <br /> Cert. c- /O Lc,fk <br /> ITA FCD <br /> sl' Todd E.Lush <br /> President <br /> L/ <br /> � 209.466.3333•fax 209.466.3336•cell 209.747.5700 <br /> 807-B Cromwell Ave.•Rough and Ready Island•Stockton,CA 95203 <br /> Email todd@capitalfmd-mm <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULT tvs( I at e <br /> Business Representative( int <br /> t Name an Title) p S pIC WHITE COPY: BUSINESS <br /> o� e i �+ REV iy <br />