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COUNTY OF SAN JOAQUIN <br /> p4 '" OFFICE OF EMERGENCY SERVICES <br /> la�cOc <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CA 95202-2709 <br /> BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> �¢ ,r/ 2,97— Z <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> 3o*-/0 e: L_A4 9rL iz_ <br /> FIRE DISTRICT INSPECTIONDATE JARRIVALTIME DEPARTURETIME INSPECTORNAMF/AGENCY <br /> 2 Z 7-Z G- 07 7: 0 C7 LarUrzc. Ake. eri/ /0FS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.Business HMMP Complete and Accurate ✓ 6.Facility Map Complete and Accurate <br /> 2.Chemical Description Pages Complete and Accurate 7.Chemical Inventory Complete and Accurate <br /> 3.Business Identification Page Complete and Accurate 8.Employees Familiar with HMMP <br /> 4.HMMP/Map Easily Accessible to Employees 9.Hazardous Materials/Waste Properly Labelled <br /> 10.Conditions noted that could increase risk of release / <br /> 5.Training/Exercise Records Available or hinder implementation of emergency lan <br /> EXPLANATION OF FINDINGS AND COMMENTS <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 Follow-Up Inspection Date Referral Actions <br /> (if appropriate) ❑SJ Ag ❑SJ Env Hlth [_]OSHA ❑Fire ❑ Air Dist <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> QXvI� � �C/YKV�I�j( I L /\ , V� PINK COPY: BUS. <br />