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AIL <br /> oAqul�` c COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> r. 2101 E. Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> cR�lFa•gN�P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> ev A R-oVif IG 1 76�5— P tvd <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPE OR NAME <br /> L2 v <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 Accurate71, 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 COMMENTS <br /> can {' r <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 /> Business Representative(Print Name and Title) B siness Rep esentative (Signat <br /> WHITE COPY: OES <br /> Top <br /> j 1 a♦ Jj . <br /> HOOC)PO )kj <br /> `� PINK COPY: BUSINESS <br /> +l l J1,d fREV 12108 <br /> 4 <br />