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oPQurN c COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Q a 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> cR•..,...,".N:P Fax:(209)953-6268 <br /> ��FOR <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Beim Inspected) <br /> k6q Lo <br /> 99 GZfljn:LF_.1 <br /> ACCOUNT[k START DAT ew Bus) I SPECrION DATF JARRIVAL TIME DEPARTURE IN 1NSP O <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 X <br /> 3.Business HMMP Complete and Accurate 18. 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 /> uy CW M <br /> d&k "' � <br /> aL K9 lum -- <br /> t wad�'_ CV <br /> t (5(11) rWAJaU <br /> AAk f <br /> KAl - G <br /> lck'(615Z <br /> - aA- I.0_1 I . <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions FReferrals/Notes: <br /> ditional <br /> To Be Submitted By: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and T'tle) Business sentafve(Signature) <br /> --[ <br /> WHITE COPY: OE5 <br /> PINK COPY, BUSINESS <br /> I REV 12/08 <br />