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PpU�N COUNTY OF SAN JOAQUIN ' <br /> aG OFFICE OF EMERGENCY SERVICES <br /> Q' ? 2101 E. Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 i CZO9)93 1 60 0 7 <br /> c°�lcN�P Fax:(209)953-6268 _ <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM Z j <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> AC OU # START ATE New Bus) INSPE ION D TE ARRIVAL TIME DEPARTURE TIME INSPECFO AMEL <br /> o✓� Z 1412-11!1 2 l �•� <br /> INSPECTION RESULTS ; I <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':l <br /> 3.Business HMMP Complete and Accurate 7. Training Records Available ' <br /> 4.Chemical Description Pages Complet nd Accurate S. Unsafe Conditions Observed(seeKiils below) <br /> EXPLANATION OF FINDINGS AND COMMEN'T'S •3 <br /> KAU <br /> CTa—L", <br /> i o u L L jVV.Qf Q Ta— 0 <br /> F <br /> M <br /> ! t <br /> I' <br /> I <br /> i <br /> �I <br /> 1 <br /> I <br /> .I` <br /> INSPECTION FOLLOW UP INFORMATION t <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 Represen v Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSI[YESS <br /> REV M 10 <br /> i <br />