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PQu(y COUNTY OF SAN JOAQUIN <br /> �o. Q.ca` OFFICE OF EMERGENCY SERVICES Wrdaq <br /> e �, 2101 E. Earhart Avenue,Suite 300 <br /> N: :< <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> C44 F O Rte`' Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> B INE MB 71D RESS Facility Being Ins cted) <br /> A OU Ji 1 START DATE(New Bus) INSP ION DATE ARRIVAL TIME DEPARTURETIM IN PE R AM <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 AL <br /> 3.Business HMMP Complete and Accurate 8. Employees Familiar with HMMP <br /> 4.Chemical Description Pages Complete and Accurate9. 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 /> ` --- <br /> on <br /> I ` 1T <br /> a <br /> tl `^ i <br /> Q <br /> D t 8 <br /> INSPECTION FOLLOW UPI&FORMATION <br /> orrective Actions Additional <br /> o Be Submitted By Referrals/Notes: <br /> CKNOWLEDGEMENT 04P REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> usmess Representative(Print Name and Ti"e) Bu a Representative( 1 Lure) <br /> WHITE COPY: OES <br /> ` PINK COPY: BUSINESS <br /> ll1 ,� y,.[r C. <br /> REV 11/n8 <br />