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P�UtN COUNTY OF SAN JOAQUIN <br /> ,. .�oo OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE $t 2 d ? <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 /> t7- r�ab, /,'� AFo0j42d 2g2Z <br /> BUSINESS ADDRESS(Facility geing Inspected) ZIPCODE <br /> 11501 f %roc- �s�/v�. o - �-t 9s'.7 7 6-::, <br /> FIRE DISTRICT ? INSSPECTI N DATE ARR AL TIME DEPARTURE TIME INSPECTOR NAME/AGENCY <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 and Accurate 7.Chemical Inventory Complete and Accurate v <br /> 3.Business Identification Page Complete and Accurate 8.Employees Familiar with HMMP <br /> 4. HMMP/Map Easily Accessible to Employees t/ 9.Hazardous Materials/Waste Properly Labelled <br /> 10.Conditions noted that could increase risk of releas <br /> 5.Training/Exercise Records Available Al or hinder implementation of emergency lan <br /> EXPLANATION OF FINDINGS AND COMMENTS \ <br /> 0/— �d�,,�i' t ` ILstsr►.` 6 f` 1 ` P¢.d b rl o r f4 <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 Follow-Up Inspection Date Referral Actions <br /> (if appropriate) [:]SJ Ag [:]SJ Env Hlth OSHA ❑Fire ❑ Air Dist <br /> A"I of /� Zooms ❑ <br /> .'KNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUS. <br /> ?AUL Lr-QttJ Te-ovi 4ti) 4i07 <br />