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o4qu, c y COUNTY OF SAN JOAQUIN *md <br /> OFFICE OF EMERGENCY SERVICES <br /> a 2101 E.Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> - <br /> Telephone:(209)953-6200 <br /> • c �r• Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(FacilityBeing Inspected) <br /> --r acz;' LC'I C 4r <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE I ARRIVAL TIME DEPARTURE TIME INSP OR NAME <br /> 61 l l0 / -� -t 1l05-d 1 11 -20 151i I ' <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible x 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 /> t v✓ d -- <br /> Co /Yi¢c t✓ QCv C` c <br /> e 4t yn%qdu rtvtIn 47'ec <br /> INSPECTION FOLLOW UP INFORNI.a"CION <br /> Corrective Actions Additional <br /> To Be Submitted By: , Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION VESULTS <br /> Business Representative(Print Name and TI e) Bu ' presen e(Si nature) <br /> " - WHITE COPY: OFS <br /> PINK COPY: BUSINESS <br /> Rev at <br />