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CPgUIp O L COUNTY OF SAN JOAQUIN `� <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> Fax:(209)953-6268 <br /> '�CrFORP <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Be' g Inspected) <br /> G cU Re d <br /> ACCOUNT# STAR (New Bus) INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME KNspEcTOR NAME <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO I FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible 5. Facility Map Complete and Accurate <br /> 2.Business Identification Page Complete&Accurate /� 6. Employees Familiar with HMMP <br /> 3.Business HMMP Complete and Accurate 7 7. Training Records Available <br /> 4.Chemical Description Pages Complete and Accurate 8. Unsafe Conditions Observed(see details below) <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> v jp 14 (2f,4vone <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESUAFS <br /> Business Representative(Print Name an Title) B ess Repre a be(Sign re) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV alo <br />