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PQuly COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a 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 /> G wl 3 1 a6am l ! <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSP OR NAME <br /> -7ttleY 3- 1 (- -1 3(6- 1 191*'-1 r <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO 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. Training Records Available <br /> 4.Chemical Description Pages Complete and Accurate 8. Unsafe Conditions Observed(see details below) -74 <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> I <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF ID 6PECTIPN RESULTS <br /> Business Representative(Print Name and Title) av3m s Representative( gn ure) t <br /> COPY: OES <br /> V _ PINK COPY: BUSINESS <br /> REva o <br />