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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E.Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> -- Telephone: (209)953-6200 <br /> FG'R • Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BU E S NAME — ADD ESS Facili[ eing Inspected) <br /> 1 ti <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE I ARRIVAL TIME IDEPARTURE TIME IN R A <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 <br /> 5.Training Records Available 10. Conditions that would hinder implementation of <br /> g Emergency Plan or increase risk of release are absent <br /> EXPLANE()xu\oxx-� <br /> COMvMMENTS <br /> f� <br /> 4— <br /> NM <br /> 1 <br /> 1HIM - S CAIIII <br /> c 16� <br /> P <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> usiness Representative(Print Name and Title) Bust s Representative(Signature) wxrrE COPY: OES <br /> /� E HS Fc c .\ •cS �;/ PINK COPY: BUSINESS <br /> A0.�n ���2t (A1gn REV <br />