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o444f" COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2r ? 2101 E.Earhart Avenue, Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> �d• •...... ••:P Fax:(209)953-6268 <br /> �tFOR� <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAMED ADDRESS(Facility Being Inspected) <br /> JAS :7:54c. .S`77 /--i L E 9J 2V7 <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME JDFPARTURE TIME INSPECTOR NAME <br /> /3570 z -/a-// //,30 /5(%-C- <br /> 11 E� <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 v <br /> 7 - all w&-3Jr Alre�j S 7a T1AAI.N/ lo <br /> t G®/r3l- 1n/11A /L.E—c 0 21 <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions _ Additional <br /> To Be Submitted By: Z 7,q— Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Ti e) Business Representana(Si nature) WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> JJ •C REV MIO <br />