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r <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />N 2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />- Telephone: (209) 953-6200 <br />�•.. (P Fact: (209) 953-6268 <br />9�iFCPN <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BU NESS NAME <br />Mt- �S C Ag <br />ADDRESS (Facility Being Inspected) <br />&&/ LIUAIL LAKo� a. 5 07 <br />ACCOUNT # <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 />✓ <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 />� — � tFiez PEYL Fc-u1� SSC—.rt-moot � /.1%STF T-�-�-zr <br />S• -S— � L � 1�I n/ c—r� r .� T -o G'riE7N/ C.4t <br />�S— i�✓�.i' �e-t-t� yir r7L �z.crrJ i F/�J� A��7�-Fs�C-TLr— �t/�T� <br />/'v 70 <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: 'a <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RE <br />TS <br />usmess Representative (Print Name and Title) Business R r <br />y X <br />s ntativ i lure) <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 4110 <br />/V- V V <br />