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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> m 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> �4(/FCN��~• Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME/ ADDRESS(Facility Being Inspected) <br /> Ll—t Y YO fZl�[_I {— 713131 E FP MO N I ST. <br /> ACCOUNT# START DATE(New Bus) INSPECPION DATE ARRIVAL TIME IDEPARTURE TIME INSPECTOR NAME <br /> /0,35'7 -3 - 11 - 0 /.-cry I <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 COMMENTS <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Tide) Business Represen tive(Sig ature) <br /> ✓l G� WHITE COPY: O SN SS <br /> S a N PINK COPY: BUSINESS <br /> J /� <br />