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nA'IN COUNTY OF SAN JOAQUIN <br /> so. .co` OFFICE OF EMERGENCY SERVICES <br /> e 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> %FFax:(209)953-6268 <br /> 4CGRH�' <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> B I ESS ME ADDRESS(Fac ilit ein nspec[ed <br /> Act <br /> ACCOUNT# START DATE(New Bus) I SION ATE ARRIVAL TIME DEPARTURE IME I SPE OR NANL <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 X <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 /> . l <br /> t �— <br /> YI vin ins m t <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> o Be Submitted By:64 7�,71MOI Referrals/Notes: <br /> ACKNOWLEDGEMENT OFJREVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative (Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> 1� OPY: BUSINESS <br /> "- S / REV 11!08 <br />