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PgUlty COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> y` < 2101 E. Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> �''• :° Fax:(209)953-6268 <br /> ,Gi c O•RiN <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BU IN S NAM \ ADDRESS(Facility Being Inspected) <br /> A OUNT k START DATE(New Bus) INSPECTION D� TE ARRIVAL TIME DEPARTE TIME I SP N <br /> —1 FRoC'Nt��ll/ � 100 <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 <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. Conditions that would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPL NATION OF FINDINGS AND COMMENTS <br /> MAaA rm I <br /> r <br /> QV'A <br /> '� <br /> 01 )z kD l <br /> Maep <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> ro Be Submitted By: CA-05—oq Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> 1 / PINK COPY: BUSINESS <br /> /�'r/ REV 12/08 <br />