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COUNTY OF SAN JOAQUIN *w4 <br /> OFFICE OF EMERGENCY SERVICES <br /> a' 2101 E.Earhart Avenue,Suite 300 <br /> ` Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> • c ,; �P Fax:(209)953-6268 <br /> •aGjpOpN <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> �� X09 z z�/S ti/ rlc� /J SZo9 <br /> ACCcyOUNT# START DATE(New Bus) INSPECTION DATE I ARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> QLL t-j <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 S. Unsafe Conditions Observed(see details below) <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEI'T OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Re esentative(Sig ature) <br /> WHITE COPY: OES <br /> (l)(� Y 11 U Cl \ PINK COPY: BUSINESS <br /> 10 <br />