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RECEIVED <br /> PgUIIy COUNTY OF SAN JOAQUIN ` <br /> OFFICE OF EMERGENCY SERVICESCOUNTY <br /> r.� <br /> 2101 E. Earhart Avenue,Suite 300 JOAQUII`�SAN <br /> a: ; :< OFFICE OF EMERGENCY SERVICE` <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> c°�iFoa��p Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> A1,451 AME * e lioADDRES (Facility Being Ins cted) <br /> r <br /> ACCOtVT# START DATE(New Bus) INTSPECT OND JARRIVALTIME IDEPARTURE TIME IN PE OR 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 8. Employees Familiar with HMMP ' <br /> 4.Chemical Description Pages Complete and Accurate 19. Hazardous Materials/Waste Properly Labelled _ --- <br /> 5.Training Records Available 0. Conditions that would hinder implementation of <br /> Emergency Plan or increase risk of release are absent <br /> EXPLANATION OF FINDINGS AND COMMENTS <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 LAIRepresentative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV 12/08 <br />