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We <br /> oP4u�N. COUNTY OF SAN JOAQUIN <br /> s.• .o� OFFICE OF EMERGENCY SERVICES <br /> `% 2101 E.Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> _-_ Telephone:(209)953-6200 <br /> Fax:(209)953-6268 <br /> �l P O'M1N <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> Y 'S et2 bio EA4em ee— LAI s- z <br /> ACCOUNT# START DXTE(New Bus) INS ION DATE I ARRIVAL TIME DEPARTURE TIME INSPECTOR NAME <br /> /&Oc?/ I --- -/Z -// /d-o c7 Ac-c-- <br /> INSPECTION <br /> c--`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) <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> INSPECTION FOLLOW UP INFOR1L%7ION <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 Representative(Signature) V k=COPY: DES <br /> o-mUn n PINK COPY: BUSINESS <br /> nEvatO <br />