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)Md COUNTY OF SAN JOAQUIN 'md <br /> °P°u'N CO OFFICE OF EMERGENCY SERVICES <br /> ��r < 2101 E.Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone-(209)953-6200 <br /> •:� -_ `p.• Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> ck Warms S'ZO S. ,2Po�T /�✓r� 9SzoS <br /> ACCOUNT# START DABus) INSPECTION DATEARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> - <br /> (09 7 3 - /z i77 0 <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Access 15. Facility Map Complete and Accurate <br /> 2.Business Identification Page Co e&Accurate 6. Employees Familiar with <br /> 3.Business HMMP p ete and Accurate 7. Train ords Available <br /> 4.Che Description Pages Complete and Accurate 8. Unsafe Conditions Observed(see details below) <br /> F77777 <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 Re ntative Si ture <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV ato <br />