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COUNTY OF SAN JOAQUIN <br />ap'°A•pp� OFFICE OF EMERGENCY SERVICES <br />a ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />STOCKTON, CA 95202-2709 <br />�IFOR� BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSIN NAME <br />TELEPHONENUMBER <br />BUSINESS ADDRESS (Facility Being Ins cted) <br />•q 1. <br />ZIP CODE <br />G W <br />FIRE DISTRICT <br />INSPECtION DATEA <br />RIVAL TIME <br />DE RTURE TIME <br />INSPECT p1ORnN•AMFIAGENCY <br />Wl <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 Accur <br />7. Chemical Inventory Complete an e <br />3. Business Identification Page Comnd Accurate <br />8. Employees Fawith HMMP <br />4. HMMP/Map Easil essible to Employees <br />9. Haz s Materials/Waste Properly Labelled <br />5. Trai ' xercise Records Available <br />1 onditions noted that could increase risk of releas <br />or hinder implementation of emergency lan <br />EXPL_1NATION OF FINDINGS AND COMMENTS <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 <br />Follow -Up Inspection Date <br />(if appropriate) <br />Referral Actions <br />�SJ Ag [—]SJ Env Hlth OSHA ❑ Fire ❑ AiF Dist <br />ACKNOWLEDGEMENT OF REVIEW AND <br />RECEIPT OF INSPECTION <br />RESULTS <br />Business Representative (Print Name and Title) <br />O� /azo o <br />Business Representative (Signature) <br />WHITE COPY: OES <br />PINK COPY: BUS. <br />am <br />V <br />