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• `" opqurN c COUNTY OF SAN JOAQUIN RCCEI <br />�?' •o� OFFICE OF EMERGENCY SERVICES <br />� <br />2101 E. Earhart Avenue, Suite 300 <br />BAR 1 <br />Stockton, California 95206 7 2011 <br />Telephone: (209) 953-6200 <br />SAN JOAQUINCOCN� <br />C9��FO.ii��P Fax: (209) 953-6268FFICE <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FOI GC NCV <br />W SINF.SS NAME <br />ADDRESS (Facility Being Inspected) <br />�(•('()I- N 1- 4 <br />START DATE (New Bus) <br />INSPECTION DATE <br />ARRIVAL TIME <br />DEPARTURE TIME <br />INSPECTOR NAME <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />5. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />6. Employees Familiar with HMMP <br />3. Business HMMP Complete and Accurate <br />7. Training Records Available <br />4. Chemical Description Pages Complete and Accurate <br />8. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />Additional <br />To Be Submitted By: <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW W %1,1) RECEIPT OF INSPECTIOV RE71 1. 17 <br />Business Representati\ c (Print Naine ;ind I itle) Business Represcntaw, ( Signature) <br />WHITE COPY OES <br />PINK COPY: ill . <br />RLQ . <br />n n1r'5 <br />