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COUNTY OF SAN JOAQUIN `o <br />vo..co` OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />-- ---: Telephone: (209) 953-6200 <br />"• Fax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />DQ [4-r,r <br />ADDRESS (Facility Being Inspected <br />�l ? 2 <br />ACCOUNTT # <br />J' <br />START DATE ew Bus) <br />INSPECTION DATE <br />`J_RRV <br />ARRIVAL TIME <br />D i ART RE TIME <br />INSPTPR NAME <br />� <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YE NO FACILITY WALK THROUGH <br />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 V <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 COMMENTS <br />INSPECTION FOLLOW UP INFORMATION <br />orrective Actions <br />To Be Submitted By: <br />Additional / <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) Busi ess Representative (Signature) _ <br />�jC p A J�cifm��✓� r <br />WHITE COPY: <br />PINK COPY: <br />OES <br />BUSINESS <br />REV 1 <br />