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pgUfN <br /> COUNTY OF SAN JOAQUIN <br /> ° cap OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE -174 /`� 7 q <br /> STOCKTON, CA 95202-2709 <br /> BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAM / TELEPHONE NUMBER <br /> BUSINESS ADDRESS (Facility Being Inspected) ZIPCODE <br /> FIRE DISTRICT IN/SP O DATE ARRI AL TIME DEPARTURE TIME INSS�PE/CTOR NAMEIAGENCY <br /> /01 CIAP—d-,j cep <br /> _Z_/0 er <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> I.Business HMMP Complete and Accurate G.Facility Map Complete and Accurate v <br /> 2.Chemical Description Pages Complete and Accurate 7.Chemical Inventory Complete and Accurate <br /> 3.Business Identification Page Complete and Accurate t/ 8. Employees Familiar with HMMP v <br /> 4. HMMP/Map Easily Accessible to Employees 9.Hazardous Materials/Waste Properly Labelled <br /> 5.Training/Exercise Records Available 110. Conditions noted that could increase risk of release <br /> or hinder implementation of emergency lan <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> /IO 7`' � ��" �` �i � vr•a-�� v � ft-e- �.�'sdvr c� �a � <br /> I <br /> l <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 /> �-7 (if appropriate) ❑S7 Ag SJ Env Hlth ❑OSHA ❑Fire Air Dist <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Repres ntative(Pf t am and Title) Business Repre tative(Si u <br /> WHITE/ <br /> PINK COPY: <br /> a�I?Y. BES <br /> US. <br /> �� 4107 <br />