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a <br />Ah <br />.a� N COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />Q ` a 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 <br />T v12 C) I' n -R_ GeG u <br />TELEPHONE NUMBER <br />(209) Z3 F - 2 45-'r- <br />BUSINESS ADDRESS (Facility Being Inspected) <br />11 I I 1Cu,v1 W a <br />ZIPCODE <br />FIRE DISTRICT <br />INSPECTIONDAEA[VALTIME <br />/ 0? <br />_2 <br />/as <br />JNAMFIAGENCY <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. Business HMMP Complete and Accu e <br />6. Facility Map Complete and Accurate <br />2. Chemical Description Pages C plete and Accurate <br />7. Chemical Inventory Complete a ccurate <br />3. Business Identification P e Complete and Accurate <br />8. Employees Familiar wi MP <br />4. HMMP/Map EasipflAccessible to Employees <br />9. Hazardous Ma sAVaste Properly Labelled <br />5. Training/E cine Records Available <br />10. Conditi s noted that could increase risk of releas <br />or hinder implementation of er enc lan <br />EXPLACNATION OF FINDINGS AND COMMENTS <br />// <br />3s c (/ A go ee0-7'ft ,c C t:. <br />/ f <br />ai lingresr: <br />l70p n E C <br />W I�LO o.4� 95 <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 />El <br />ACKNOWLEDGEMENT OF REVIEW AND <br />RECEIPT OF INSPECTION <br />RESULTS <br />Business Representative (Print Name and Title) <br />Busines esen five ' nature) <br />WHITE COPY: OPS <br />PINK COPY: BUS. <br />4/07 <br />