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opa!!!N. COUNTY OF SAN JOA( <br /> _'` ''�� OFFICE OF EMERGENCY SERVICES <br /> ¢ 2101 E. Earhart Avenue, Suite 300 <br /> a: � <br /> u: e <br /> Stockton,California 95206 <br /> _ ` Telephone: (209)953-6200 <br /> c4�iaoRrs'• Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUS NESS NAME ]7�� ADDRESS(Facility Being Inspected) <br /> VJ�n <br /> ACCOUNT# TART DATE(New Bus) I SP IOFN <br /> N DATE ARRIVAL TIME DEPARTUR TIME SP O NA <br /> lVIn <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 /> orrective Actions Additional <br /> o Be Submitted By: Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Bus ess Re resentattve(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV l2/ <br />