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oPqu!N, COUNTY OF SAN JOAQUIN <br /> �. '.o <br /> 2,• •.c OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue,Suite 300 .� / <br /> Stockton, Califomia 95206 tt <br /> Telephone:(209)953-6200 <br /> t`•d�/FaRii�P Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS N ADDRESS(Facility Being Inspected) <br /> ACCO START D (New Bus) INSPECTION DAVE ARRIVAL TIME DEPARTURE TIME INPECT <br /> L <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 Comple Accurate 6. Employees Familiar with HMMP <br /> 3.Business HMMP Com and Accurate 7. Training Records Ava' <br /> 4.Chemical cription Pages Complete and Accurate 8. Un onditions Observed(see details below) <br /> EXPLANATION OF FINDINGS AND COMMENTS - <br /> C <br /> \� �- <br /> MEXICAN GRILL <br /> ASHLEY BELL <br /> GENERAL MANAGER <br /> wnccr 209.371.08 CNIPOTLE MEXICAN GRILL,INC. <br /> sA` 2 9.9001 I 2310 TIENDA DRIVE <br /> INSPECTION FOLLOW UP INFORMATION LODI.CA 95242 <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 Title) Business Represents ' e( ignature) <br /> WHITE COPY: OES <br /> PE,-TK COPY: BUSINESS <br /> REV 4110 <br />