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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ? 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> " Telephone:(209)953-6200 <br /> C,GI F G Ra.P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> ACCOUNI <br /> # ST RT DATE(New Bus) INSZEC-rION DATE ARRIVAL TIME DEPAR URE TIME IN PECTO A <br /> G.IJ <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 /> m 040 . 17f,4� 1I <br /> -� O - I`A -O <br /> 1 <br /> u S <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: ` Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> usiness Representative(Print Name and Title) Business Representative(Signature) WHITE COPY: DES <br /> U, 1/+ QL1 `^ `1vVV."^ PINK COPY: BUSINESS <br /> v� \ REV 12/08 <br />