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oa�ly COUNTY OF SAN JOAQUIN <br /> o°' 'Eos OFFICE OF EMERGENCY SERVICES <br /> 2101 E.Earhart Avenue,Suite 300 <br /> 0: 1 ` Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> �'••. �P Fax:(209)953-6268 <br /> 4ci c oN`' <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BU ESS N ME - L10 ADDR7S(Facility Being Inspected), <br /> A OUNT# START ATE(New Bus) IN PF ON DATE ARRIVALTIME'DEPARTURE TIME INSP AMID <br /> INSPECTION RESULTS 1/1//��/I <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 ]0. Conditions that would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> 51 \ <br /> l - -09 <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective L Actions V Additional <br /> S <br /> To Be Submitted By V Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Bu - ess Representat v Signature) <br /> Soma �� OES <br /> PINK COPY: <br /> BUS <br /> PINK COPY: BUSINESS <br /> REV 12/08 <br />