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aPqu(N C COUN'T'Y OF SAN JOAQ <br /> a —l'•oma OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue,Suite 300 <br /> Stockton, California 95206 <br /> Telephone:(209)953-6200 <br /> FFax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) / ,, <br /> c --/:>o�-".& . S X25-7G��— '—P —cs /—/ 1%A4E� Z, 07 <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE I ARRIVAL TIME DEPARTURE TIMEINSPECTOR NAGE <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 /> i <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 /> Business Representative(Print Name and Title) Business Re resentative(Signature) <br /> WHITE COPY: OES_ <br /> +4--ml <br /> .L i ` ��� rA n 1_ _ �nA K <br /> PINK COPY: BUSS 440 <br />