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Pou,N COUNTY OF SAN JOAQUIN ReGEIVED <br />0' <' OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 APR —6 2011 <br />Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />Fax: (209) 953-6268 SAN JOAQUIN COUNTY <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM OFFICE OF EMERGENCY SERVICE <br />BUSINESS NAME <br />ADDRESS (Facility Being Inspected) <br />\e'COUNT /k <br />START DATE (New Bus) <br />INSPECTION DATE <br />ARRIVAL TIME <br />IDEPARTURE TIME <br />INSPECTOR NAME <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 />6. Employees Familiar with HMMP <br />3. Business HNIMP 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 ('P INFORMATION <br />'orrecti�e Actions <br />To Be Suhmitted By: <br />Additional <br />Referral,/Notes: <br />CKNo %VLED(,ENIEN-l' OH' Rl- \11•:N\ kNU ltb.('I.:IPT OF INSPE(,'I'ION KESLL'I'S <br />Businr,s Representative (Print '\.une ;uxl I itle) <br />Business Representative (Signature) <br />i <br />W HITE COM nF� <br />PINK COP' <br />5 a C r <br />