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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 />FORNFax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINEO NAMEI <br />ADDRESS (Fa c'Ity <br />Being Inspected <br />In <br />ACCQU <br /># <br />START DATE (New B ) <br />jkN P <br />ION D TE <br />OFn <br />RIVAL TIME <br />DEPARTURE TIME <br />IN E OR AM <br />DOCUMENT REVIEW <br />INSPECTION RESULTS <br />YES NO FACILITY WALK THROUGH <br />YES NO <br />. 1. HMMP/Map On Hand and Easily Accessible <br />6. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />7. Presence of Non-Listed Regulated Chemicals <br />X <br />, 1 <br />3. Business HMMP Complete and Accurate <br />8. Employees Familiar with HMMP <br />4. Chemical Description Pages Complete and Accurate <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training Records Available <br />V <br />1 <br />10. Conditions that would hinder implementation of <br />Emergency Plan or increase risk of release are absent <br />EXPLANATION OF FINDINGS AND COMMENTS <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />ef+trL.:S -9IZQ"0 t vvwRNAkI <br />Business Representative ignature) <br />WHITE COPY: <br />PINK COPY: <br />OES <br />BUSINESS <br />REV 12/08 <br />