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o44u1N. COUNTY OF SAN JOAQUIN - <br /> ? ' ''•9� OFFICE OF EMERGENCY SERVICES u <br /> 2101 E. Earhart Avenue,Suite 300 <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSI S NAME DDRESS(Facility Being Inspected) <br /> A <br /> GlC�9�(///d6 /P/lf�LS / 2-- / g e oWpAlre54< f4,331 <br /> ACCOUNT# START DATE()(ew Bus) INSPECTION DATE ARRIVAL TIME IDEPARTUIWTIME INSPCTOR NAME <br /> INSPE TION RESULTS <br /> DOCUMENT REVIEW YES70FACILITY 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 9,r 6 . Unsafe Conditions Observed(see details below) <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> /✓ / DiJ�N�/Dnp u� l0 Fib T /l✓iw .v <br /> GG <br /> d� <br /> o hliv C6io o`• <br /> E6 � <br /> Ilcf/•t/GLS-� �!� 6' lc� 6ir/ z� ✓DstiJ / l.�d. <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> To Be Submitted By: 9�& Referrals/Notes: ,i(/O IV <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> 'c WHITE COPY: OES <br /> _r �yJ/V t PINK COPY: BUSINESS <br /> ( x ,c dP &6 REV alo <br />