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I oay{urr� o COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ! _ ? 2101 E. Earhart Avenue, Suite 300 <br /> ` Stockton,California 95206 <br /> i Telephone: (209)953-6200 <br /> l c��f i O Ra:p Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BU INESS NA JADDRESS(Facility eing Inspected) <br /> r <br /> 'ximp 12& <br /> ACCOUNT t START DATE(New Bus) INSPECTION DATE JARRIVALTIME DEPAR URETIME INSPECTOR NAME 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 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 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 /> Jw� <br /> INSPECTION FOLLOW UP INFORMATION <br /> i7orrective Actions Additional <br /> o Be Submitted By: ReferralslNotes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OE5 <br /> i <br /> PINK COPY: BUSINESS <br /> REV 12/08 <br /> I <br /> ! <br />