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'COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ?., ROOM 610, COURTHOUSE <br /> H: 222 EAST WEBER AVENUE :F <br /> STOCKTON, CA 95202-2709 <br /> ' <br /> c�` + oR`'`P BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME i - TELEPHONE NUMBER <br /> BUSINESS AIJDRESS (Facility Being Inspected) ZIPCODE <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME INSPECTOR NAMEIAGENCY <br /> i Ir--G(X.y C IIDEPARTURETIME <br /> I q(6-- Pl-4, <br /> y-L el <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.Business HMMP Complete and Accurate / 6. Facility Map Complete and Accurate <br /> w <br /> 2.Chemical Description Pages Complete and Accurate 7. Chemical Inventory Complete and Accurate <br /> r <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 <br /> 5. Training/Exercise Records Available 10.Conditions noted that could increase risk of release <br /> or hinder implementation of 6mergency plan <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> �� y( C ylrQnf 0C f <br /> W cc <br /> ;I <br /> - 7 I <br /> i <br /> i <br /> SII <br /> 4! k <br /> R+ <br /> I� <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. <br /> INSPECTION FOLLOW-UP INFORMATION f <br /> Corrective Actions Must Be Submitted By Follow-Up Inspection Date Referral Actions <br /> (if appropriate) SJ Ag ❑SJ Env HIth OSHA Fire ❑ Air Dist <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> 1/n m L�! �� • q� � PINK COPY: BUS. <br /> 7 C! 4/47 <br />