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Pn�,H 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 />�`, •.:p Fax: (209) 953-6268 <br />GIFPN <br />G <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />4 e ed-CD <br />ADDRESS (Facility Being Inspected) <br />l-15- <br />15-15- HCIC70 <br />ACCO <br />ACCO # <br />p <br />START DATE (New Bus) <br />/ <br />JINSPECTION DATE <br />Jr i <br />ARRIVAL TIME <br />j O� <br />IDEPARTURE TIME <br />I <br />INSPO NAME <br />YO <br />01,7 11 <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <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 />8. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />f emee t✓t c7 ca <br />a n -e vi <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions / <br />To Be Submitted By: <br />Additional <br />Referrals/Notes:� <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION aESULTS <br />Business Representative (Print Name and Title) Busr ss flepresentative (Signature) <br />WHITE COPY: OES <br />n v I^ /� YL� / PINK COPY: BUSINESS <br />REV M 0 <br />