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oPgUlty C COUNTY OF SAN JOAQUIN We <br /> �.• ',o� OFFICE OF EMERGENCY SERVICES <br /> _ ? 2101 E.Earhart Avenue,Suite 300 <br /> N: [ <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> ikb'n`'�P <br /> Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSIN NA A SS( acility 1gem nspected �. <br /> I <br /> ACCOUNT# START/DATE(New Bus) INSPECTION DATE A RIVAL TIME DEPARTURE T ME INSPE OR A <br /> O <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Ac Bible 5. Facility Map Complete and Accurate <br /> 2.Business Identification Pa omplete&Accurate 6. Employees Familiar wi MP <br /> 3.Business HMMP plete and Accurate 7. Training RAvailable <br /> 4.Chemica escription Pages Complete and Accurate 8. U e Conditions Observed(see details below) <br /> EXXfANATION OF FINDINGS AND COMMENTS <br /> 209 62, <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) Busi Representative(Signature) <br /> WHITE COPY: OES <br /> 160�L PINK COPY: BUSINESS <br /> REV 4110 <br /> I L)j <br />