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quit' �✓ 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 /> c4�i c 6'A�'sp Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> .ACCOUNT# START DATE(New Bus)1INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTOR!NAME <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 ve'- 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 /> Z— v�usi.J�s .�ez �s ro mus_ '� c c <br /> CD �eT� <br /> INSPECTION FOLLOW ITP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: 2- - / S-- // Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Pont Name and Title) I Business Represe rive(Signature) <br /> �y}'/� WHR"E COPY: OES <br /> Iv n y� r�(7� ✓ '" �/ PINK COPY: BUSINESS <br /> ✓� F— Are-r REV alo <br /> 0 <br />