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COUNTY OF SAN JOAQUI <br /> �4PR hoc OFFICE OF EMERGENCY SERVICES <br /> 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 TELEPHONENUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> FIRE DISTRICT �� INSPECCIONDATE JARRIVALTME� DEPARTURE TIME I INSP TORNA AGENCY <br /> —o <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 an21 urate 7.Chemical Inventory Complete and ate <br /> 3.Business Identification Page C ete and Accurate 8. Employees Familiar w' MP <br /> 4. HMMP/Map Easil cessible to Employees 9.Hazardous nals/Waste Properly Labelled <br /> 10.C Ions noted that could increase risk of release <br /> 5.Train ercise Records Available or hinder implementation of emer enc lan <br /> XPLINATION OF FINDINGS AND COMMENTS <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 /> Busi s Representative(Print Name and Title) Business Representative(Signature) <br /> J WHITELOPY OES <br /> PINK COPY: BUS. <br /> am <br />