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' OPgUI/y^ c COUNTY OF SAN JOAQUIN <br />• ?r �� OFFICE OF EMERGENCY SERVICES <br />r.� <br />Zj 2101 E. Earhart Avenue, Suite 300 MARS <br />Stockton, California 95206 <br />• Telephone: (209) 953-6200 SAN JOAQUIN COUNTY <br />C4 6- ��P Fax: (209) 953-6268 OFFICE OF EMERGENCY SERVICES <br /><<FR <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />ADDRESS (Facility Beina Inspected) <br />ACCOUNT # <br />START DATE (New Bus) <br />INSPECTION DATE I <br />ARRIVAL TIME <br />DEPARTURE FI`iE <br />INSPECTOR NA\IE <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 Op FINDINGS AND COMMENTS , <br />ri <. <br />I .d .. — <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />o Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIE NN kND RECEIPT OF INSPECTION REy( LTS <br />Busin:„ kcrresentative (Print Namc-and Title) <br />Business Representative (Si nature) <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 4110 <br />MAR 0 7 RECT <br />