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aPQuly o COUNTY OF SAN JOAQUIN 1 <br /> OFFICE OF EMERGENCY SERVICES <br /> aj 2101 E. Earhart Avenue,Suite 300 <br /> a: <br /> Stockton,California 95206 <br /> _= Telephone: (209)953-6200 <br /> �dC/FOP4`P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME I ADDRESS(Facility Being Inspected) <br /> Uri <br /> ACCO NT& START DATE(New Bus) INSPECTION DATE ARRIVALTIME DEPARTURETIME INSPECPOR�NAME <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 /> Bu ness Representative(Print Name and Title) B mess Representative(Signature) <br /> O U ViG— UiP�o75 / {�$�C�Gt //� PINK COPY: BUSINESS <br /> ✓' ' ✓` � —" REV 17J08 <br />