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PQ ,N COUNTY OF SAN JOAQUIN <br /> �o. .coG 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 /> <%FGRN <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAMEADDRESS(Facility Being Inspected) <br /> S h� 6 l 6 Ry Bae-lo'nd <br /> ACCOUNT# S ART DATE(New Bus) INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME INSPE OR NAME <br /> / 2-1 -� I i 3b 1-.)-/o a ✓/ s <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 8. 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 RECEIPT OF INSPECTION RESULTS <br /> usiness Representative(Print Name and Title) Busin Representative(Sign re) COPY: OES_ <br /> LQ J PINK COPY: BUSINESS <br /> f\/ " REV 4/10 <br />