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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2` s ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE -*/Z 81(:::' <br /> STOCKTON, CA 95202-2709 <br /> BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONENUMBER <br /> A TX T 0-to6; /4Y 100-4.71P-01P z z <br /> BUSINESS ADDRESS(Facility Beifig Inspected) ZIPCODE <br /> L-o w.-// v Q, r� 4.s3 7 61�' <br /> FIRE DISTRICT INSPFM <br /> 0NDATE JARRIVALTIN4E DE ARTURE TIME INSPECTOR NAME/AGENCY <br /> -7-;;c,c- JA4, <br /> OCUMENT 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 /> 5.Training/Exercise Records Available of 10.Conditions noted that could increase risk of releas , <br /> or hinder implementation of emergency lan <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> S' <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 /> . <br /> KN2nEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> y�/� ,( PINK COPY: BUS. <br /> L 1�1 1�N, A t(, ) G G C 40 t 4/07 <br />