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COUNTY OF SAN JOAQUIN <br /> ?• '•9a OFFICE OF EMERGENCY SERVICES <br /> a 2101 E.Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> eqC/FORa�e <br /> Fax: (209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM C <br /> BUSINESS NAME ADDRESS(Facility Be' g Inspected) <br /> AI-1,4 hierO AN12�lkl lel P'S IIWV /:;10.4 <br /> ACCOUNT# START DATE(New Bus) INSPECT N D TE ME ARRIVAL TIDEPAR ME TIINSPECTO <br /> � oZ6 a3� e� 2s— 1f0 �Pad� e- 2- <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 V 6. Employees Familiar with HMMP <br /> 3.Business HMMP Complete and Accurate 7. Training Records Available V, A <br /> 4.Chemical Description Pages Complete and Accurate 8. Unsafe Conditions Observed(see details below) <br /> EXPLANAATION OF FINDINGS AND COMMENTS <br /> • x - 11 11 OV,- e- ` - W er 15 V, A-1la <br /> O.,VUOLk n tr0 <br /> c_ <br /> 4 Y r /2 <br /> Ci0'[il G.., K 4.,i "� Q !/O n,, <br /> t+E(P — Ta f�i` ;cc✓i a�-` �Gt� :a e u -�w p l o e � W � Li e- «�/"1�, <br /> -2 ev ✓OU lo'tQ <br /> INSPECTION FOLLOW UP INFO TION <br /> Corrective Actionsf d 2 g .9 Additional <br /> To Be Submitted By: 1 Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Busi s Re resen ve(Signature) <br /> WHITE COPY: OES <br /> J /n n � Sr PINK COPY BUSINESS <br /> � <br /> REV 4/10 <br />