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OpQUIN c ""� COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> r ? 2101 E. Earhart Avenue, Suite 300 <br /> P: <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> P�' ��'• Fax:(209)953-6268 <br /> �IFCRN <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> ms's .,lie.. ** e/iftr 2c�ioH Ln/. 9SZo7 <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> 03 3 7- 7- ©9 oo <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 v <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 /> fo 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: OFS <br /> PINK COPY: BUSINESS <br /> /7 V \ REV 12/ <br />