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PgUl,y COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Q` ? 2101 E. Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> Far:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Bein Inspected) <br /> l <br /> ACC UNT# START DATE(Nfv Bus) INSPECTION DATE ARRIVAL ME DEPARTU TIME INSP OR IIIAME <br /> / - -c41 I 10� 1 <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 /> 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) Busin s Represen[a a(Signature WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV 12!08 <br />