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PQuly COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Q 2101 E. Ear4art Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> C4<�FORaxP Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> s'u3c%4y S.¢r/9c/�cpf�S GT?" Al6rlt Ajr flzct5" <br /> ACCOUNT k START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPARTURE 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 ete&Accurate 7. Presence of Non-Listed e Chemicals <br /> 3.Business HM mplete and Accurate 8. Emplo amiliar with HMMP <br /> 4.Ch cal 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 /> EXPLANATION OF FINDINGS AND COMMENTS <br /> Ci 7tt S. cow — <br /> zoo..-" -� ©o <br /> leu sin/c�s f � dni r/ 7M7 !•✓tet Zc�o . <br /> A/6-79—f Pa-CA L_ �_(w A A <br /> Qfiflr`lr VZ - 2S-f© c z� <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RE TS <br /> Business Representative(Print Name and Title) Business Re pr s tattve�naturj) <br /> J06/^j <br /> D O o WHITE COPY: US <br /> FN u p PINK COPY: BUSINES ESS <br /> 1_ 1'V�Qvta U ttEv ivos <br />