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COUNTY OF SAN JOAQUIN <br />°Quf N OFFICE OF EMERGENCY SERVICES <br />' a ROOM 610, COURTHOUSE <br />y' 222 EAST WEBER AVENUE 19t /Z 7 y `f <br />... - ...;P STOCKTON, CA 95202-2709 <br />°�1FORN BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />o ,-1, `6 <br />TELEPHONE NUMBER <br />oft -63�z z <br />BUSINESS ADDRESS (Facility Being Inspect <br />`SS/ 266 -e—v 1". �sCA <br />ZIP CODE <br />FIRE DISTRICT <br />INSP IO DATE <br />JAIMIVALTIME <br />DEPARTURE TIlvIE <br />INSPECTOR NAME/AGENCY <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. Business HMMP Complete and Accurate <br />✓ <br />6. Facility Map Complete and Accurate <br />2. Chemical Description Pages Complete and Accurate <br />7. Chemical Inventory Complete and Accurate <br />3. Business Identification Page Complete and Accurate <br />✓ <br />8. Employees Familiar with HMMP <br />✓ <br />4. HMMP/Map Easily Accessible to Employees <br />+� <br />9. Hazardous Materials/Waste Properly Labelled <br />✓ <br />5. Training/Exercise Records Available <br />10. Conditions noted that could increase risk of release <br />or hinder implementation of emergency lan <br />EXPLANATION OF FINDINGS AND COMMENTS <br />7 4_/7 14 2 <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 ❑ Air Dist <br />_i,KNOWLEDGEMENT OF REVIEW AND <br />RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />L <br />Pga' l? 11 C ii <br />Business Representative (Signature) <br />WHITE COPY: OES <br />PINK COPY: BUS. <br />4/07 <br />