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• PgUiN COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />' Telephone: (209) 953-6200 <br />cq�i F o,R�:P Fax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />I `:tE��� <br />MAR 2 9 2011 <br />SAN JOAOUIN <br />OFFICE F EMERGECCYU E VIC ES <br />13USINESS NAME <br />ADDRESS (Facility Being Inspected) <br />ACC'Ot \-i <br />START DATE (New Bus) <br />INSPE$/TION DATE <br />ARRIVAL TIME <br />DEPARTURE TIME <br />JINSPECTOP, NAME <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />;.. <br />5. Facility Map Complete and Accurate <br />�..- <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 />. Chemical Description Pages Complete and Accurate <br />8. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />INSPECTION FOLLOW CP INFORMATION <br />Corrective Actions <br />To Be Submitted By: ! <br />Additional <br />Referrals/Notes: <br />CKNOWLEDGENIENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />usiness Representative (Print Nance and fitle) <br />Business Representative (Si -nature) <br />` <br />WHITE COPY: OES <br />PINK COPY: BUSINE� � <br />REV 4, <br />