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T 1 <br /> AWL <br /> COUNTY OF SAN JOAQUIN <br /> °naU1N. ° OFFICE OF EMERGENCY SERVICES <br /> a a 2101 E. Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> �'•: . :P Fax: (209)953-6268 <br /> aciFo'n`'' <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS N ME ADDRESS <br /> n(Facilit Being Inspected <br /> ACCOUNT# START DATE( Bus) Iti P I N DE ARRIVAL TIME DEPARTUR TIME I SPECT R N E <br /> LM 12 --lfl1 S <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 <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 /> _O I <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> Co Be Submitted By: Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Re Si ature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV 17108 <br />