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os4� COUNTY OF SAN JOAQUIN +� <br /> ?'� '•oma OFFICE OF EMERGENCY SERVICES <br /> r` 2101 E. Earhart Avenue, Suite 300 <br /> e: <br /> e ` Stockton,California 95206 <br /> _- Telephone: (209)953-6200 <br /> �`''• Fax:(209)953-6268 <br /> 'fit F 0'RN�' <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> GILL o,a t 5 /✓ s A M & 20 s­ <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME INSPECTOR NAME <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 /> L�tA I NO-r A-tl 4_71(_t7, 7-0 (�e'�`� c9 C9� <br /> IT- uStnt <br /> % 3 - L-A,S-( IS A(o 7- C0.dPLt_7't7 f}c C2 no,�t c— ro <br /> 3� ee yetr9O N« e P r /71- <br /> r-_N- <br /> j. <br /> i <br /> �S - CMOs ✓� rc) eFrz <br /> 77f e— N tAt&- A_1N n/eTe�S 7-o ze— wr- rb �r <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions G Additional <br /> fo Be Submitted By: 6 ' 0 - 09 Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> ,MZ U 1 O --T, <br /> PINK COPY: BUSINESS <br /> l� 425 P REV l <br />