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oP4� k. COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> Q` a 2101 E.Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> C,��PC'ita`P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSIN SS NAME ADDRESS(Facility Being Inspected) <br /> L I - K Se✓v a 1P v.,,y qR u e <br /> ACCOUNT# START DATE(New us) INSPECTION D�AtTE ARR/I�V�A�L/ D <br /> TIME 9EPAR TIME INSPE OR NAM <br /> 0371 <br /> It <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 /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: / Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS 17 <br /> Business Representative(Print Name and Title) Busines Repre a tata Signatu <br /> PINKCOPY: O REV SS <br /> 111hop PINK C COPY: BUSINESS <br />