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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> r' Z ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE #/Z- 79,F <br /> �. STOCKTON, CA 95202-2709 <br /> BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSS NAME TELEPHONE NUMBER <br /> 1 a_Z -,Ikl ZS-SSD- 94.0'0Z <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIPCODE <br /> 0 % o,r ova Zoe $ C_ 9 5-Z© �i <br /> FIRE DISTRIC NSP ION ATE ARRIVAL TIME DEPARTURE TIME INSPECTOR NAME/AGENCY 1 % <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGIf YES NO <br /> 1.Business HMMP Complete and Accurate 6.Facility Map Complete and Accurate <br /> 2.Chemical Description Pages Complete and Accurate 7.Chemical Inventory Complete and Accurate ci <br /> 3.Business Identification Page Complete and Accurate i, 8. Employees Familiar with HMMP <br /> 4. HMMP/Map Easily Accessible to Employees 9.Hazardous Materials/Waste Properly Labelled <br /> / 10.Conditions noted that could increase risk of releas <br /> 5.Training/Exercise Records Available /(! or hinder implementation of emergency Ian <br /> EXPLANATION OF.FINDINGS AND COMMENTS <br /> jc 7L C_a gKet-t 7:. QAC_�_ <br /> cB lrlo <br /> Jp_ CL _e 4 14 <br /> /..r 4t e W 4011 - <br /> NOTE: <br /> 011 -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 Follow-Up Inspection Date Referral Actions <br /> e„. (if appropriate) El <br /> SJ Ag SJ Em Hlth OSHA Fire Air Dist <br /> jLkt,-et, 1 -712-609- ❑ <br /> CKNOWLEDGE T OV—WVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Re went ve(Pr t Na e d Title) Business Repres ativ ( ature) <br /> WHITE COPY: OES <br /> PINK COPY: BUS. <br /> 4/07 <br />