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P4tu1N COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Q 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> -=` Telephone:(209)953-6200 <br /> Cq•. �P <br /> Fax:(209)953-6268 <br /> �iFGRN <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUST SS NA E ADDRESS(Facility Being Inspected) <br /> a ✓ to a <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME INSPE OR NAME <br /> �0 i l( - 1 '2 l 15'� <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 /> 2 t4 L V1 ' <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Rep r ive(Signature) <br /> WHITE COPY: OES <br /> U( PINK COPY: BUSINESS <br /> REV 17108 <br />