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COUNTY OF SAN JOAQUIN <br />? OFFICE OF EMERGENCY SERVICES <br />Q ?� 2101 E. Earhart Avenue, Suite 300 <br />` Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />oq�l F o'aN�P Fax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUS SS NAME <br />CMIN 6 ►Lr .=-/-i/rCE-1/g-7C) <br />ADDRESS (Facility Being Inspected) <br />�AIAI- Xve-, ,�os-- <br />ACCOUNT #, <br />START DAT New Bus) <br />Z �� <br />INSPECTION DATE <br />�-Z57- // <br />ARRIVAL TIME <br />,�cr-o <br />DEPARTURE TIME <br />jINSPjCTOR NAME <br />�l/J� <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Acces ' <br />5. Facility Map Complete and Accurate <br />_ <br />2. Business Identification P omplete & Accurate <br />6. Employees Famili MP <br />3. Business H Complete and Accurate <br />7 ping Records Available <br />emical Description Pages Complete and Accurateb. <br />PEXPLANATION <br />Unsafe Conditions Observed (see details below) <br />OF FINDINGS AND COMMENTS <br />CAMS Bim/' .si r� <br />L d /f <br />;-�c�c�?� <br />c/�/c� X�li4Mc LNr <br />0 <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />Ulvwc�LJ <br />//C -Y� /L�c/�} /✓ <br />Business Repre entative (Signature) <br />� <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 4110 <br />M <br />