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p Pp U,(N C 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 /> Fax:(209)953-6268 <br /> 4�+Foar <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Insppted) <br /> Skt rn M�' lf c7x6- l�w u <br /> ACCOUNT k START DATE(New B INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> IUL 5��� � (Ul ) I l( a <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 Y 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 /> �i, �ov�-c � Cq� li�ir.�}r.✓ <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 /> usiness Representative(Print Name and Tit e) Business esentative(Si lure) <br /> WHITE COPY: OES <br /> Lf� <br /> r/ i,•J PINK COPY: BUSINESS <br /> v J(j [��/ REV 171 <br />