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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />a ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />... j ...;P STOCKTON, CA 95202-2709 <br />BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME I <br />Ot f F 1 _ <br />TELEPHONE NUMBERAay / <br />�' (v <br />BUSINESS ADDRESS (Facility Being Inspectek <br />b q 2 N , I%A�� Au <br />ZIP CODE <br />9 S' Z q- C") <br />FIRE DISTRICT <br />INSP nONDATE <br />JARRIVdLTIME <br />o g o <br />DEPARTURE TIME <br />o <br />INSPECTOR NAMEIAGENCY <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. Business HMMP Complete and Accurate <br />6. Facility Map Complete and Accurate <br />2. Chemical Description Pages Complete and Accurate <br />7. Chemical Inventory Complete and Accurate <br />3. Business Identification Page Complete and Accurate <br />jvlo <br />8. Employees Familiar with HMMP <br />4. HMMP/Map Easily Accessible to Employees <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training/Exercise Records Available <br />N A <br />10. Conditions noted that could increase risk of release <br />or hinder implementation of emergency lan <br />EXPLANATION OF FINDINGS AND COMMENTS <br />e—.ti t.J a r �� I �L O <br />-:Le-; � • <br />NOTE: All HMMP documents except for the Facility Map can be created and updated on the San Joaquin County <br />HMMP Compliance Website at www.sjoesdata.org. Contact OES for user name and password. <br />INSPECTION FOLLOW-UP INFORMATION <br />Corrective Actions Must Be Submitted By <br />T 21 200 <br />Follow -Up Inspection Date <br />(if appropriate) <br />Referral Actions <br />SJ Ag [:]SJ Env Hlth OSHA [:]Fire [:]Air Dist <br />.CKNOWLEI)GEMENT OF REVIEW AND <br />RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) Business Representative (Signature) <br />-2 2 j aCt4 tc , <br />WHITE COP]BUS. <br />PINK COPY:_ <br />