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oF4ulN. --i 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 /> +~ �'dtico"ai'(P• Fax:(209)953-6268 Y-2-77 HAZARDOUS MATERIALS PROGRAM INSPECTION FORM Cy S 2-7 7 <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) p / <br /> T / 'r-r 2 , f j 0 0(.K ro <br /> ACCOUNT#. START DATE(New Bus) INSP ION ATE ARRIVAL TIME DEPARTURE TIME INSP CT R N E <br /> S /J ' 2^1 //3C> <br /> 3 � 11,5_C> <br /> , � O S <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible 5. Facility Map Complete and Accurate <br /> 2.Business Identification Page Complete&Accurate 6. Employees Familiar with HMMP <br /> 3.Business HMMP Complete and Accurate 7. Training Records Available <br /> 4.Chemical Description Pages Complete and Accurate 8. Unsafe Conditions Observed(see details below) <br /> EXPLANATION OF FINDINGS AND C NIMENTS / <br /> No ✓Y 4C. 1 0,44 e I01 e—C ' <br /> INSPECTION FOLLOW UP INFORMATION <br /> orrective Actions Additional <br /> Submitted By: Referrals/Notes: <br /> �bKNOWLEDGEMENT OF KEVIEW AND RECEIPT OF INSPECTION RESULTS <br /> (u/ssii'�nness��s--yy��yeepresentati.v�e(Print Name and Title) <br /> Business Representative(Signature) <br /> �t,/'t"�'e �'t{iz he t-1 O,SI�'L - PINK COPY: <br /> O SINREV SS <br /> PINK COPY: BUSINESS <br />