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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES I <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 'VAR 2 9 2011 <br />Telephone: (209) 953-6200 SAN �pgQ��N <br />c��/FoaN�P Fax: (209) 953-6268 OFFICE CO Ty <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM OFENIFRGFNCySF <br />BUSINESS NAME <br />ADDRESS (Facility Being Inspected) <br />ACCOUNT tt <br />START DATE (New Bus) <br />JINSPECTION I)ATE <br />ARRIVAL TIME <br />IDEPARTURE TINIEI <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 />5. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />h. 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 />EXPAATION DINGS AND COMMENTS <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Note,,: <br />CKNOWLEDGEMENT OF REVIENV'.%ND RECEIPT OF INSPEC'TWN RESt LTS <br />ff-usiness Representative (Print Name an j Iitle) <br />Business Repre;enwke (Siumiture) <br />TE COPY: OES <br />K COPY: BUsf`:; . <br />rVN <br />