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Ah <br /> op°•u�N• COUNTY OF SAN JOAQUIN <br /> ?• '•90 OFFICE OF EMERGENCY SERVICES <br /> a` ? 2101 E. Earhart Avenue, Suite 300 <br /> N: :< <br /> • Stockton,California 95206 <br /> Telephone:(209)953-6200200 <br /> ' ..6.1 P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> B SS N — n ADDRESS(Facility Being Inspected) <br /> ACCy # START DVALTEE( w Bus) IITECTIO 1AATE ARRIVAL TIME DEPARTURE TIME INSPECT N E <br /> C_J C/�1 <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible5. 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 /> b <br /> INSPECTION FOLLOW UP INFORMATION <br /> ctive Actions Additional <br /> e Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS4 <br /> R0 <br />