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COUNTY OF SAN JOAQU <br /> 'AUl" OFFICE OF EMERGENCY SERVICES <br /> 'a�'c°o <br /> u` 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 TELEPHONE NUM BER <br /> et, cri 6-CLf "6- 3 <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> 2 GLG q 5-3 ?G <br /> FIRE DISTRICT INSPECTION DATE JARRIVALTIMr DEPARTURE TIME I INSPECT NAMEIAGENCY <br /> a- 3 Q d 13 <br /> a <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 <br /> 3.Business Identification Page Complete and Accurate 8. Employees Familiar with HMMP <br /> 4. HMMP/Map Easily Accessible to Employees 71— 9.Hazardous Materials/Waste Properly Labelled <br /> 10.Conditions noted that could increase risk of release <br /> 5.Training/Exercise Records Available or hinder implementation of emergency lan <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> dart-" <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 ❑OSI�A ❑Fire ❑ Air Dist <br /> ❑ J% <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Si nature) <br /> 7 WHITE COPY: OES <br /> PINK COPY: BUS. <br /> Q 4/07 <br />