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Pqury COUNTY OF SAN JOAQUIN RECEI <br />OFFICE OF EMERGENCY SERVICES ` <br />: _ zj 2101 E. Earhart Avenue, Suite 300 MA� 2011 <br />Stockton, California 95206 <br />c P Telephone: (209) 953-6200 <br />4�I RC'R <br />Fax: (209) 953-6268 SAN JOAQUIN COUNTY � OFFICE OF EMERGENCY SERVICE <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM SERVICE, <br />BUSINESS NAME <br />ADDRESS (Facility Being Inspected) <br />ACCOUNT # <br />START DATE (New Bus) <br />INSPECTION DATE <br />ARRIVAL TIME <br />DEP/ARTURE TIME <br />r <br />JINSPECTORN_�',[L <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />If <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 />18.Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />INSPEC'T'ION FOLLOW UP INFORNIATION <br />Corrective Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AN 1) RECEIPT OF IN'SPEC'TION RESl1.TS <br />Business Representative (Print Name and Title) <br />r <br />Business Representative (Signature) <br />WHITE COPY. ()F.,, <br />PINK COPY! Rf',1', . <br />a <br />KAR 0 7 REU <br />