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Pqulq COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a` ? 2101 E. Earhart Avenue,Suite 300 <br /> e " Stockton,California 95206 <br /> ` <br /> Telephone:(209)953-6200 <br /> c'P<icc'ii��P Fac:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINETSS NAME /} (� 1 ADDRESS <br /> (Facility Being Inspected) <br /> 5•.•. Jun• �:.. �-o,r...� U'VF'ica o'l- la�'lCc.'tlo �9// <br /> ACCOUNT# START DAT (New Bus) INSP ION PATE I ARRIVAL TIME DEPARTURE TIME jINSftCTOR iy.4ME <br /> ± / '7� /o 1 In q-s // 10 <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 Accurat <br /> 2.Business Identification Page Complete ccurate 7. Presence of Non-Listed Regula Chemicals <br /> 3.Business HMMP Complete and curate 8. Employees Familiar wit MMP <br /> 4.Chemical Descriptio[[ es Complete and Accurate 9. Hazardous Mate ' s/Waste Properly Labelled <br /> 5.Training Recor Available 10. Conditions t would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS B <br /> L Ze✓- <br /> I <br /> o owV^ C C,.- 0% .Q_ G 1 1 All� <br /> Co 4_C_ + ,' 30 V% W <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) Business R,ppresenta ive(Signature) WHITE COPY: OES <br /> J UNNh �W �y�/� PINK COPY: BUSINESS <br /> REV 17103 <br />