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PQuIN `/ COUNTY OF SAN JOAQUIN <br /> so. .coG OFFICE OF EMERGENCY SERVICES <br /> r` 2101 E. Earhart Avenue,Suite 300 <br /> r: `z <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM 9 s Z 0 r <br /> BUSINESS)A E ADDRESS(]Facility Bein Inspected) <br /> AC OUNT# START DATE(New Bus)JINSPECTIO,N DATE ARRIVAL TIME IDEPARTURE TIME INSPEerOR NAME <br /> 3�,7 2_ 1 /3 0 1 /,S3 <br /> �L l <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 Comple[ Accurate 7. Presence of Non-Listed Regulated C icals <br /> 3.Business HMMP Complete Accurate 8. Employees Familiar with HM <br /> 4.Chemical Descripti f ages Complete and Accurate 9. Hazardous Materials/Wag a Properly Labelled <br /> 5.Training Records Available 10. Conditions that wrould hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS I A/ <br /> I A �f OO t /, of e r I( .� ca.�k 0'x I'C <br /> Add resJ .' �.�- t? 0.. /X <br /> INSPECTION10 <br /> FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> o Be Submitted By: -?.� Referrals/Notes: <br /> WKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Busmess Representative(Print Name and Title) Basin ss epresentative(Signature) <br /> WHITE COPY: OES <br /> r <br /> PINK COPY: BUSINESS <br /> aBvivoa <br />