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o4A�IN 1./ COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> "---. Telephone:(209)953-6200 <br /> Fax: (209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSIN SNAME ADDRESS(Facility Bein Ins cted) <br /> (Al II - <br /> AC # START DATE ew Bus) INS ECrI N DATE ER ARRIVAL TIME DEPARTURE TIME INS AM <br /> UNT <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 X <br /> 3.Business HMMP Complete and Accurate 8. Employees Familiar with HMMP X <br /> 4.Chemical Description Pages Complete and Accurate 9. Hazardous Materials/Waste Properly Labelled <br /> 5.Training Records Available0. Conditions that would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> l � <br /> � V1I yw <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective ActionsAdditional <br /> To Be Submitted By Referrals/Notes: <br /> CKNOWLEDGEM NT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business resentative( ignature <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV tv <br />