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oPA"IK COUNTY OF SAN JOAQUIN <br /> '•9� OFFICE OF EMERGENCY SERVICES <br /> a' a 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> �q•: _ :� <br /> Fax:(209)953-6268 <br /> �i p oki' <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> E ms's z�--a o5< E. ,ua� Lnl s2in <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME INSPECTOR NAME <br /> 2-09 i 4/0-0 1 <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES N 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 Com Accurate 7. Presence of Non-Listed Re hemicals <br /> 3.Business HMMP Co e and Accurate 8. Employe iliar with HMMP <br /> 4.Chemical scription Pages Complete and Accurateaaardous 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 /> X14 S 0^/ i re- <br /> A s tt-� <br /> Vic-T-0/Z 5 ILS I_ O o <br /> e-!7 7 zS.scP <br /> ':'-- 4 4 S- - l l ( 3 <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RES <br /> Business Representative(Print Name and Title) Businyss Rep a the(Signature) <br /> WHITE COPY: OES <br /> X X PINK COPY: BUSINESS <br /> REV 12/08 <br />