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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />UX` .Z< 2101 E. Earhart Avenue, Suite 300 L� <br />Stockton, California 95206 MAR 17 2011 <br />Telephone: (209) 953-6200 <br />NJO <br />Cq' •.....• ' �P Fax: (209) 953-6268 Sq AQUIN CO <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORN1FFICEOFEME UNTV <br />BUSINESS NAME <br />Vi' iT "':IdiLi'T'f <br />ADDRESS (Facility Being Inspected) l <br />-'7 <br />1..i <br />ACCOUNT # <br />START DATE (New Bus) <br />INSPECTION DATE JARRIVALTINIE <br />DEPARTURE TIME <br />I INSPECTOR NAME <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessiblev' <br />5. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />6. Employees Familiar with HMP <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 />r - -- <br />INSPECTION FOLLOW CP INFOR.1:'t TION <br />orrecti�e Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW kNI) RECEIPT OF INSPECTION RFS[ LTS <br />Business Representative (Print Name and Title) <br />Business Representative (Signature) <br />WHITE COPY: OFS <br />PINK COPY: BI SI`,' <br />