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Pfxu1N COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2r 2101 E. Earhart Avenue,Suite 300 <br /> Q: a <br /> Stockton,California 95206 Rtp� <br /> Telephone:(209)953-6200 <br /> Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ;a ADDRESS(Facility Being Inspected) <br /> ACCOUNT It SI' RT DATE(New Bus) INSPECI'IO DATE ARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> 7fO �✓/� <br /> 7/ <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 Sd A6./Presence of Non-Listed Regulated Chemicals <br /> 3.Business HMMP Complete and Accurate 669 8. Employees Familiar with HMMP <br /> SG6 <br /> 4.Chemical Description Pages Complete and Accurate 9. Hazardous Materials/Waste Properly Labelled <br /> 5.Training Records Available ati ^% Conditions that would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> / /l0 6vC�11� d S! 6 a.ir ,a Ldp4e <br /> �sr � �✓cC d lx.,� CCi rc. lSf/ <br /> •�� Coc.oTe iw z-.s�a' /6�io.✓ am dc< T Kr our, <br /> ✓v��S'o ca�.,o��� �airt� r o Zc( aL1 r6�6 <br /> �'66C f�a-L6'� �.fY.t/6.SS f�it/�/r1 r Oit/ cfl�B/ls�rd'��,�'4G66.ti�i1'rd' <br /> 2 3ZL %n/6S' Av �O >o is ,iii' �iws�Saw.vd�Z.l7 151ley�,OVPoO <br /> -A, <br /> ��_ y' 0 <br /> /1-1�67KC' <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> f Submitted By: Referrals/Notes: <br /> AIRMOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Bus' ess Representative(Print Name and Title) Busin s present ive(Signature) <br /> WHITE COPY: OF <br /> S <br /> < < r PINK COPY: BUSINESS <br /> REV 17108 <br />