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COUNTY OF SAN JOAQUI <br /> OFFICE OF EMERGENCY SERVICES <br /> 2` ? 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 NUMBER <br /> BUSINESS ADDRES Facilit Being Inspect d) Z C D <br /> 6 N <br /> DI TRACT INSPECTION DAtEARRWAL TIME DEPARTUWTIME INSPECT RN ME/AGENCY <br /> D105 1 - S <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 Ac 7.Chemical Inventory Complete a ccurate <br /> 3.Business Identification Page C <br /> >Wlfre and Accurate 8. Employees Familiar MMP <br /> 4. HMMP/Map Ea i ccessible to Employees 9.Hazardous rials/Waste Properly Labelled <br /> 5.Trai ' xercise Records Available 10._C (tions noted that could increase risk of releas <br /> or hinder implementation of emerge lan <br /> EXPLAANAATION OF FINDINGS AND COMMENTS <br /> Vel I l_.Fil n <br /> chs co 7 - - <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 /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Si tune) <br /> WHITE COPY: OES <br /> + BUS� PINK COPY: BUS. <br /> 4/07 <br />