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Ad <br /> A3ii I <br /> pouiN COUNTY OF SAN JOAQUIN <br /> �o.. ...coc OFFICE OF EMERGENCY SERVICES <br /> y 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> c'•. : Fax:(209)953-6268 <br /> 'P�iP6�H <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> B INFISS NAIME \ 0 ADDRlintESS(Facility Being Inspect d) <br /> ACCOUNT# START DATE(New Bus) INSPECTION TE ARRIVAL TIME DEPARTURE TIME IN PE , OR AM <br /> 5�130IC <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&Accuratc 7. Presence of Non-Listed Regulated Chemicals <br /> 3.Business HMMP Complete and Accurate 8. Employees Familiar with HMMP x <br /> 4.Chemical Description Pages Complete and Accurate 9. 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 <br /> 'MC COMMENT'S <br /> 1 V v\ <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> o Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Sig ature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> IE S t ( IMV I2108 <br />