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i`*� COUNTY OF SAN JOAQUIN ftw <br /> OFFICE OF EMERGENCY SERVICES <br /> _ Z 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facilit Beind- wwg Inspected) �� <br /> Mir CJ r1,� 61U <br /> ACCOUNT# START DATE(New Bus)JINSPECTION DATE ARRIVAL TIME IDEPARTURETIME INSPE OR NAME <br /> U ` I U f�Z� Get `J' (/f of ✓t 15 <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 1 48. Employees Familiar with HMMP <br /> 4.Chemical Description Pages Complete and Accurate 9. Hazardous Materials/Waste Properly Labelled <br /> S.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 /> Llf �- J10 re,14d <br /> Ca t d a <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions �L Additional / <br /> To Be Submitted By: �,� l Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Busin Repres nta ve(Signature) <br /> 940 �j �� � WHITE COPY: OES <br /> f-T PINK COPY: BUSINESS <br /> REV 1 <br />