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COUNTY OF SAN JOAQUIle <br />OFFICE OF EMERGENCY SERVICES <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 />% q* 6 33k <br />BUSINESS ADDRESS ((Facility Being Inspected) G ZIPCODE <br />FIRE DISTRICT <br />u <br />INSPECTION DATE <br />�^ c� <br />ARRNA TIME <br />1_ Of6' <br />DEPARTU TIME <br />I v <br />SP T R NAMFJAGENCY <br />iolq ( I <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 />-is <br />2. Chemical Description Pages Complete and Accurate <br />7. Chemical Inventory Complete and Accurate <br />3. Business Identification Page Complete and Accurate <br />4. HMMP/Map Easily Accessible to Employees <br />8. Employees Familiar with HMMP <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training/Exercise Records Available <br />10. Conditions noted that could increase risk of release`l <br />or hinder implementation of emergency lan <br />lj <br />EXPLANATION OF FINDINGS AND COMMENTS <br />�irl`�c c� <br />ctrl w <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 DES 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 />Si Ag —]SJ Env Hlth ]OSHA _] Fire [:]Air Dist <br />10 <br />ACKNOWLEDGEMENT OF REVIEW AND <br />RECEIPT OF INSPECTION <br />RESULTS <br />psiness Representative (Print Name and Title) <br />.. , <br />Business Representative (Signature) <br />WHI1'B COPY: OFS <br />PINK COPY: BUS. <br />M07 <br />