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Alk <br />PAy,N COUNTY OF SAN JOAQUIN MW <br />�o..coG OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />" --_ Telephone: (209) 953-6200 <br />N<� F O'fRi+ Fax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS E <br />D <br />(Facil"ty Being Ins cted) <br />AC <br />STAR DATE(New Bus)INSPECTIOONDATE <br />22 <br />ARRIVALTIME <br />DEPARTURE TIME <br />IN ECr N <br />ME <br />DOCUMENT REVIEW <br />INSPECTION RESULTS <br />YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />6. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />7. Presence of Non -Listed Regulated Chemicals <br />3. Business HMMP Complete and Accurate <br />8. Employees Familiar with HMMP <br />4. Chemical Description Pages Complete and Accurate <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training Records Available <br />10. Conditions that would hinder implementation of <br />Emergency Plan or increase risk of release are absent <br />EXPLANATION OF FINDINGS AND COMMENT'S <br />�+ 0 8-03-0 <br />1A Qxa1 <br />U0 P <br />Cin <br />NSPECTION FOLLOW UP INFORMATION <br />orrective Actions �� 1 <br />o Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT O REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative tPrint Name and Title) <br />^ �� ^ <br />w to <br />BMsss ti St nature) <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 12108 <br />mug <br />