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opµuty COUNTY OF SAN JOAQUIN <br /> oma OFFICE OF EMERGENCY SERVICES <br /> m 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> ' Telephone: (209)953-6200 <br /> Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> �Sua .iy Sro�e -reel4tf/li /6"8 h+'c'1�vG6Y <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME JINSPCTOR NAME <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 j <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 f <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 /> /�l•G Sl�efi.S d��fi4G/�t /�.xiD�t��urt,vl/� S/�h2A .S <br /> w/ <br /> �.�-d�S ,�.� � �iS�d /0,�,.�✓yO�d.�J /lti7,�s 6�i6✓,v�' <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: ivoiv� <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) WHITE COPY: OES <br /> 4 PINK COPY: BUSINESS <br /> REV 121081 <br />