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PStUIN COUNTY OF SAN JOAQUIN <br /> aa .co` OFFICE OF EMERGENCY SERVICES <br /> m 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> • Telephone:(209)953-6200 <br /> �,f•.%Pd• NiP <br /> Fax:(209)953-6268 9 5-2, p <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME T ADDRESS(Facility B�ei`}�Inspe ed)/ 1 <br /> GX ✓ZS.r / ✓a,n.f eu i' c� �S N. (,✓G– <br /> ACCO # START DATE(New Bus) INSPION IL TIME DEPARTURE TIME INSPECT R NA <br /> �Z�TE ARRIVAL <br /> o �3Zo /3 ,7.S l� <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessib 6. Facility Map Complete and Accura <br /> 2.Business Identification Page Co mpl &Accurate 7. Presence of Non-Listed Regul d Chemicals <br /> 3.Business HMMP Complete Accurate 8. Employees Familiar wit MMP <br /> 4.Chemical Descriptio <br /> ges Complete and Accurate 9. Hazardous Mate ' s/Waste Properly Labelled <br /> 5.Training Re s Available 10. Condition at would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> ll �/ ,L G <br /> t4 044 (.l / / 1 0 (/2 To <br /> tV 14)40.r L11,04 <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 Representative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> Ohm eSevt I REV 12/08 <br />