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ANIL <br /> PAWN C• low 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 /> Fax:(209)953-6268 <br /> FC RA <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> �/lP O S S�oc <br /> AC OUNT# START DATE(New us) INSP ION DATE ARRIVAL TIME IDEPARTUREXIME JINSPECTOR <br /> 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 FINDING AND COMME L <br /> O -C_ Q f O r O f Lc1Cc,�/ •� O/ / q.K0/ <br /> � O i <br /> p -I-,oi'ccc 'n ilea © r <br /> AO 17 4-1 <br /> AIL 57 <br /> Q <br /> rti c.�if- f G /O'.7 .T• (moi /!!//.1' {� a <br /> 2 c �/1• <br /> INSPECTION FOLLOW UP INFO ATION <br /> Corrective Actions ^ L z� Additional <br /> To Be Submitted By: `� Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECT[ ESULTS <br /> Business Representative(Print Name and Title) Busi ss Repr sentative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> REV a10 <br />