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oPt�uly COUNTY OF SAN JOAQUIN qW <br /> OFFICE OF EMERGENCY SERVICES <br /> r. 2101 E. Earhart Avenue, Suite 300 <br /> H Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> C'��%FCRN`P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> "Mr <br /> U N S 1ygME ADD ESS(F ilit Bein Inspected) <br /> 1 f\ <br /> ACCOUNT# START DA E(New Bus) INSPECTION DATE ARRIV L TIME EP RTURE ME [IN*E R NTE <br /> 5 ti <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 /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> fo Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDgLWENT OF REVIEW AN RECEIPT OF INSPECTIO ES LTS <br /> Business Rep se tive(Print Name an it c Busmes Repr en ive(Signature) <br /> WHITE COPY: US U� PINK COPY: BUSINESS <br /> REV 12/08 <br />