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' PquIN COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES �` I V <br />to: 4 2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 IVO 2 9 <br />201, <br />Telephone: (209) 953-6200 <br />Fax: 953-6268 JFF/CEO� <br />(209) <br />fMEQUINUUUN <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAMETI <br />DDRESS (Facility Being Inspected) EP <br />-1T s r <br />ACCOUNT # <br />START DATE (New Bus) <br />INSPECTION PA FE I <br />ARRIVAL TIME <br />IDEPARTURE TIME <br />INSPECTOR NAME <br />J <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 />8. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />jAdditional <br />To Be Submitted By: 1 ,' <br />Referrals/Notes: <br />CKNOWLEDGEMI I u N II kND RECEIPT OF INSPECTION RESGLTS <br />Business Representati\; i'rint N�trte and Title) <br />Business Representative (Sicnature) <br />+ s <br />WHITECOPY: OES <br />PINK COPY: BUSINESS <br />` <br />REV J+'10 <br />