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PqulN COUNTY OF SAN JOAQUIN l <br /> so. .coG OFFICE OF EMERGENCY SERVICES i <br /> a a 2101 E. Earhart Avenue,Suite 300 <br /> ` Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> cy�iFo. H�P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINES NAME ADDRESS(Facility Being Inspected) <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPARTUR�3I14E I INSPEC R NAME <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 11 <br /> 3.Business HMMP Complete and Accurate 7. Training Records Available <br /> 4.Chemical Description Pages Complete and Accurate <br /> 18. Unsafe Conditions Observed(see details below) <br /> �i <br /> EXPLANATION OF FINDINGS AND COMMENTS {t <br /> i� <br /> a: <br /> l� <br /> i� <br /> Yr <br /> ii <br /> �i <br /> .j <br /> It ' <br /> INSPECTION FOLLOW UP INFORMATION s <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ,L <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECFCYNRESUIASII <br /> Business Representative(Print Name and Title) Bus' esU7 prese tat Signature) <br /> pp � WHITE COPY: OES <br /> 74-t-Al 1� 6�i�( � 'C,,_, PINK COPY: BUSINESS <br /> i REV 4/10 <br /> ,7 <br />