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o.�'O'"'l N• c <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> x' 2101 E. Earhart Avenue, Suite 300 <br /> Q: .a <br /> Stockton,California 95206 <br /> •' '• <br /> Telephone: (209)953-6200 <br /> p4Gii=o ��o Fax: (209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSI E5 NAMEADDRESS(Facility Being Inspected) ��ZO� <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPARTUR1-TI E INSPE R N MFS <br /> i �2 � 7 / z7 �e /ZZs- <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> I.HMMP/Map On Hand and Easily Accessible 6. Facility Map Complete and Accurate <br /> 2.Business Identification Page Complete&Accurate t/ 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 . 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 /> EXPLANATIONOFFINDINGS AND COMMENTS <br /> W ar 2� <br /> rk:?.V <br /> ,NO• � <br /> VID, <br /> Q f e <br /> / 7r )4 c-o /4— (�!'1 er�,�c o✓ liC CEJ / <br /> 6,1 /1-41 41211'.1 <br /> il- / <br /> INSPECTION FOLLOW UP INFO MATION <br /> Corrective Actions Additional <br /> To Be Submitted By: 2— 9 Z 0/(5 1 Referrals/Notes: <br /> ACKNOWLEDGEMENTfOF JJEVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Bus'ness Representative(Signature) WHITE COPY: OES <br /> �h ��_•H I�� e i J '�„� <br /> PINK COPY: BUSINESS <br /> REV 12/ <br />