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COUNTY OF SAN JOAQUIN` - <br /> �o ` coa OFFICE OF EMERGENCY SERVICES i <br /> r` 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 ADDRESS(Facility Being Inspected) IP CODE <br /> 2 o z5 k/ 8a a e__!//0 V7 A C/ kAo P7 95z03 <br /> FIRE DISTRICT INSPECTIONTE ARRIVAL TIME D DEPARTURE TIME INSPECTOR NAMEIAGENCY <br /> joC/�Ovr IZ`(o�6 7 �Z/-?0 f -2-(5 <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> I.Business HMIVLP Complete and Accurate W16.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 9.Hazardous Materials/Waste Properly Labelled 1 <br /> Conditions noted that could increase risk of releas <br /> 1 4 V 5.Training/Exercise Records Available or hinder implementation of emer ency Ilan <br /> i <br /> I EXPLANATION OF FINDINGS AND COMMENTS <br /> i <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. j <br /> INSPECTION FOLLOW-UP INFORMATION <br /> Corrective Actions Must Be Submitted By Follow-Up Inspection Date Referral Actions <br /> (iappropriate) 11 SJ Ag ❑SJ Env Hlth OSHA ❑Fire Air Dist <br /> L _ , <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) f d <br /> J Amt ,SDr�—/ COPY: S <br /> PINK C BU <br /> PINK COPY: BUS. � <br /> i 4107 <br /> i <br /> r' } <br /> J <br />