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e4AutN COUNTY OF SAN JOAQUIN` �- <br /> ?'' ':� OFFICE OF EMERGENCY SERVICES <br /> f: 2 <br /> 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> P�'� (' • Fax:(209)953-6268 <br /> �%PCS~ <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> Q(At "-KE-r - k3 2-7-955- e: L fzos- <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECIOR NAME <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible .VI"' 6. Facility Map Complete and Accurate r <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. Conditionsthat would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> mss ' A copV, ©ra I,�tc ,ems-C-0 sl <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions2 _ Additional <br /> o Be Submitted By: Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> usmess Representative(Print Name and Title) Business Representative(Sign ture) <br /> WHITE COPY: OES <br /> x KUE MwA CSN E{� x PINK COPY: BUSINESS <br /> f't t` rzsv Ives <br />