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PgUiN COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue,Suite 300 <br /> a: < <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> LAC <br /> NAME ADDRESS(Facility Be ng Ins ct ) <br /> UNT lk START DATE(New Bus) IN PECHON DATE I ARRIVAL TIME DETIME INSP Cr R N ME <br /> /``'{j�l I //ll''//\\ � <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 X <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 /> YZAA NN \1 P U <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> o Be Submitted By:Nw 1 'Znq Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTIO ESU <br /> usmess resentanve(Print Name and Tit e) Bus tne eprese to ' tgnature) <br /> WnrrE COPY: OES <br /> / PINK COPY: BUSINESS <br /> REV 121081 <br />