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COUNTY OFW JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />c' • - .P Fax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BU S N ME <br />-'�,1S�.r► <br />ADDRESS (Facility Being Inspected) <br />S� <br />ACCOUNT # <br />SI S <br />START DATE (New Bus) <br />INSPEVI01 DATE <br />2 ' - —Zoc1 <br />ARRIVAL TIME <br />13 2 -!S -J3 <br />IDEPARTW TIME <br />6 <br />INSPE OR N <br />�o Lo �z <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH <br />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 />-- <br />18. Unsafe Conditions Observed (see details below) <br />T T,ANATION OF FINDINGS AND COMMENTS <br />INSPECTION FOLLOW UP INFO TION <br />Corrective Actions <br />�e Submitted By: A,111+ <br />Additional <br />Referrals/Notes: <br />__>NOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />usin s Representative (Print Name and Title) <br />'^ <br />r `�U <br />Bu ' s R Sent gnature) <br />t <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 4110 <br />