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o-�ury COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 4 a 2101 E. Earhart Avenue,Suite 300 _v <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> �'•. �P Fax:(209)953-6268 <br /> R�IFORN . <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM Sr Z4 rr, <br /> BUS SS NAME T^ ADDRESS(Facility Being Inspected) <br /> "I i C-C tH ?qc,'�✓t y vt C . 7 S L.� ✓ O•—'}` <br /> ACCOUNT# START DATE(New Bus) INSPEC ION D TE ARRIVAL TIME DEPARTURE IME INSPECTppR NA <br /> -15-t o sero ?-o< /6 o a 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. Empfoyees 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 /> VA- U <br /> I b i 0— C1 Q 1 yrs c3 c 4'L <br /> INSPECTION FOLLOW ETP INFORMATION <br /> Corrective Actions ^� Additional <br /> To Be Submitted By: eJ�,�, .4 2�7 L Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION 4EAUItrS <br /> [Bainess Representative(Print Name and Title) Busi ess Re re a tat've(Signature} <br /> WHITE COPY: OES <br /> PINK COPY: $UR VEv o <br />