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`• qurN COUNTY OF SAN JOAQUIN I 7U) CE►VE <br />�o.coG OFFICE OF EMERGENCY SERVICES <br />a ?� 2101 E. Earhart Avenue, Suite 300 MAR 2 9 ?,�1j <br />Stockton, California 95206 <br />Telephone: (209) 953-6200 SAN Jp <br />c,�(FCRa�P <br />Fax: (209) 953-6268 OFFICEOFEM <br />RG NCY NR <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />ADDRESS (Facility Being Inspected) <br />ACCOUNT # <br />START DATE (New Bus) <br />INSPECTION DATEJARRIVAL <br />TIME <br />DEPARTURE TI,NIE <br />INSP CTOR NAME <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />i- <br />' <br />5. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />6. Employees Familiar with HMMP <br />3. Business HMMP Complete and Accurate <br />7. Training Records Available <br />4. Chemical Description Pages Complete and Accurate <br />Unsafe Conditions Observed (see details below) <br />J8. <br />EXPLANATION OF FINDINGS AND COMMENTS <br />ti <br />i <br />INSPECTION FOLLOW L•P INFOR)I:LTION <br />orrecti%e Actions <br />Additional <br />To Be Submitted By: <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RE,"I 1 1 <br />Business Representative (Print Name and "Title) <br />Business Reprc-cmative (JI4,Uature) <br />WHITE COPY: ( 0 <br />PINK COPY: BU,)I`.! <br />R <br />