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O PQy�N O L COUNTY OF SAN JOAQUIN `.0 <br />OFFICE OF EMERGENCY SERVICES <br />Q T 2101 E. Earhart Avenue, Suite 300 <br />" k ` Stockton, California 95206 <br />-:- Telephone: (209) 953-6200 <br />C,�IFOPN�' Far.: (209) 953-6268 <br />HAZARDOUS ATERIALS PROGRAM INSPECTION FORM <br />4UfIr,JESS NAME <br />) <br />A SS Facility <br />Bein nspec d) <br />ACCOUNJ# <br />START DATE (New Bus) <br />INSPECTION D TE <br />ARRIVALTIME <br />IDEPARTURETINLE INS E R <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 />1 <br />6. 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 />EXPLANATION OF FINDINGS AND COMMENTS <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name andTitle) <br />usiness Representative (Signature) <br />FJL� <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />