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o>4'IM. COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a` j 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> 46- <br /> N�p Fax: (209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> 1;/ a16 T I fro lc 270 Z Al. .v1A�ca 1 LHt 9Sz l Cl <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE I ARRIVAL TIME DEPARTURE TIME INSAPECTOR NAME <br /> OF /TZ-t-t� <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 rate 7. Presence of Non-Listed a[ed Chemicals <br /> 3. Business HMMP CompleAccurate 8. Emplo amihar with HMMP <br /> 4.Chemi11 <br /> cal D tption Pages Complete and Accurate . 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 /> 517.3- 3& 9s-- <br /> Arro <br /> ®old JAMIE RUBEN <br /> GENARAL MANAGER <br /> GENAstockton-gm@osf.com <br /> The Old Spaghetti Factory, Inc. <br /> 2702 West March Lane <br /> Stockton,CA 95219 <br /> Telephone(209)473-3695 Facsimile(209)473-3698 <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 /> n WHITE COPY: OES <br /> X &'L P� SV V\'-A!� ,- _\ Iry, PINK COPY: BUSINESS <br /> REV 17/03 <br />