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Qp4F1IN C COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a: a <br /> 2101 E.Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone: (209)953-6200 <br /> c,Ci Fo aN�P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> it ✓ l 5-a 5 lj9C <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME DEPART IME INSP OR NAME <br /> I <br /> Oct.)- <br /> q_3 -/D �/�li l 12 � <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 /> dLLw <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional / <br /> To Be Submitted By: Referrals/Notes: <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative Print Name and Title) Business R resentative(Signature) <br /> !JCKC COPY: <br /> PINK <br /> IN` PINK COPY: BUSINESS <br /> REVa10 <br />