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COUNTY OF SAN JOAQUIN <br /> ao. .co` OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> ` Telephone:(209)953-6200 <br /> Fac:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facilit Bein Inspecte <br /> J401 �0 Zr <br /> ACCOUNT k I START DATE(New Bus) INSPECTION DATEARRIVAL TIME DEPARTURE TIME INSPECTOR ME <br /> Cl �Y4U 15�� <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YESNO 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 /> 171- Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> �i✓Y�c d c� t k <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> o Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Busmes Representative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> r REV 1 <br />