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F�,,,,y 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 /> • �...,,,....,.'0 • Fax:(209)953-6268 <br /> �IFORN HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NkE ADDRESS(Facility eing Inspected) <br /> WC <br /> r .e 'i/ <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE I ARRIVAL TIME IDEPARTUVIETIME INSPE OR NAME <br /> 7 '9 1ZQ`t 103c/ 10155, <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> t.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 /> b u da we7 &ra <br /> �t t Wt J hl —c N1 Pt c r1.c <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> AMRP.Submitted By: Referrals/Notes: <br /> ATKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> siness Representative(Print Name and Title) Business epresentative( gnature) WHITE COPY: OES <br /> PINK COPY: ROSINESS <br /> df r'Yrs 1✓ <br /> REV 12/08 <br />