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COUNTY OF SAN JOAQUIN <br /> a4Q�t"' OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CA 95202-2709 <br /> Ca�1FC'RN�P BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONENUMBERr <br /> v <br /> BUSINESS ADDRESS(Facility Being InsppS d) ZIP CODE <br /> q`5220 <br /> FIRE DISTRICT INPECTION DA ARRIVAL TIME IDEPARTURETIMEP <br /> ETOR NA AGENCY <br /> _I —O <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 a curate 7.Chemical Inventory Complete and A to <br /> 3.Business Identification Pa plete and Accurate 8. Employees Familiar wi MP <br /> 4. HMMP/Mapgwilf'Accessible to Employees 9.Hazardous tals/Waste Properly Labelled <br /> . 10.Co ' ions noted that could increase risk of release <br /> 5mg/Exercise Records Available <br /> or hinder implementation of emerizencv vlan <br /> EXPLANATI F F DINGS AND COMMENTS <br /> IT <br /> 4A OVA Wn <br /> NOTE: All HMMP Jocuments except for the Facility Map can be created and updated on the San Joaquin County <br /> IIMMP 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 /> El <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE <br /> COPY: OES <br /> PINK COPY: BUS <br /> . <br /> ,0 <br /> Cz�o�- <br />