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MDR <br />ti oPqurN c COUNTY OF SAN JOAQUIN 7 J 1� <br />OFFICE OF EMERGENCY SERVICES / <br />Q a 2101 E. Earhart Avenue, Suite 300 MAR 2 9 2011 <br />a' ` <br />` Stockton, California 9206 <br />Telephone: (209) 953-6200 O SAN�pgQN� <br />cqG%RORN�P Fax: (209) 953-6268 FFICEOFEMER� �C � - <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM - SCC, <br />M 'sINESS NAME <br />ADDRESS (Facility Being Inspected) <br />- r—T. - <br />r <br />A( c c )l Nl',� <br />START DATE (New Bus) <br />INSPECTION DATE JARRIVALTINIE <br />IDEPARTURETINIE <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 />$. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND CO;WMENTS <br />I` <br />1 <br />INSPECTION FOLLOW I P INFORYLvTION <br />Corrective Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Notes: <br />CKNOWLEDGENIENT OF RF% 11.1% %ND RECEIPT OF INSPECTION RF.SUL'rS <br />Business Representati%e (Print Name ;incl l'itle) <br />t <br />i <br />Business Representative tSi_natttre) <br />WHITE COPY: OES <br />PINK COPY: BUSINEti', <br />RE\ ; <br />