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two <br /> Pauly COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a t 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> ' '- Telephone: (209)953-6200 <br /> :P Fac:(209)953-6268 <br /> 4G%PORN <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME �/ ADDRESS(Facility Being <br /> yInspected) p <br /> / /fc_.o —2 � i//4'LLf1 LSr07 5//_ <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATEARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> 390 7 -zi-o9 ism <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 p,-' 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 /> Business Representative (Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> \ REV 17108 <br />