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Aft <br /> P�u,y COUNTY OF SAN JOAQUIN MW <br /> OFFICE OF EMERGENCY SERVICES <br /> e' 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> Fax:(209)953-6268 <br /> 9C%FbNN <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME P I ADDRESS(Facility Being Inspected) <br /> ACCOUNT# STA T ATE(New Bus) INSP ION DATE ARRIVA TIME DEPAjZj U E TIME I P O NA <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 S. 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 /> EXPLANATION OF FINDIINnGS AND COMMENTS <br /> ,, c©zan! <br /> 4907 E.Waterloo Road <br /> Stockton, CA 95215-2096 <br /> Phone: (209)931-3093 ext. 14 <br /> Toll Free:(800)242-6023 <br /> Fax: (209)931-5654 WILLIAYt McCLELLAND <br /> E-mail:safety(pcozad.net Safety Director <br /> www.cozactrailers.com <br /> t ` <br /> i <br /> INSPECTION FOLLOW UP INFORMAT119N <br /> orrective Actions Additional <br /> o Be Submitted By: Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Busine s Re sentaC a(Si a e <br /> WHITE COPY: OES <br /> C -�{ PINK COPY: BUSINESS <br /> � fl e h C reelREV 17108 <br />