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ity�^hr—a� rrew <br />~ ' PqutN COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICESc <br />MAR 17 /10fl' <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 SAN JOAQUIN COUNTY <br />' = Telephone: (209) 953-6200 OFFICE OF EMERGENCY SERVICES <br />c°�iFo'RN�p Fax: (209) 953-6268 <br />HAZARDOUS MATERI_ALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />ADDRESS (Facility Being Inspected) <br />ACCOUNT # <br />START DATE (New Bus) <br />INSPECTION DATE JARRIVALTIME <br />DEP.ART_ URE TIME <br />F <br />INSPE OR N. -\`IE <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 LP INFORMATION <br />Corrective Actions <br />To Be Submitted Bv: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEN� k \ It RECEIPT OF INSPECI'ION RESL LTS <br />Business Representative 1 Print ,same and l itle) Business Representative (Signature) <br />WHITE COPY: OES <br />! PINK COPY: BUSINESS <br />REV 4/10 <br />MAR 0 7 RECD <br />