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PQ,urN COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 VAR 2 9 201, <br />Telephone: (209) 953-6200 <br />cqt+Fo.a�;:° Fax: (209) 953-6268 ('CCSAAj jo (JI <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FOR�IVTEOFEN1ERGN00UTY <br />BUSINESS NAMEADDRESS <br />(Facility Being Inspected) <br />t <br />ACCOUNT .# <br />t r° <br />START DATE(New Bus) <br />INSPEC'IONDATE <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 />3. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate6. <br />Employees Familiar with HMMP <br />3. Business HMMP Complete and Accurate <br />?. 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 FOLLONV t'P LNFORM:ITION <br />Corrective Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW .SND RECEIPT OF INSPECTION RESULTS I <br />Business Representajke (Print Name and Title) <br />ij <br />Business Rcprc�ientatke (Signature) <br />( <br />kk i-IFFE COPY: OES <br />PINK COPY: BI .l <br />