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COUNTY OF SAN JOAQUIN <br /> ?ate c°.c OFFICE OF EMERGENCY SERVICES <br /> r. ? ROOM 610, COURTHOUSE <br /> �'. 222 EAST WEBER AVENUE #3 1? 7 0- <br /> • C,�., ,.. .a(P• STOCKTON, CA 95202-2709 <br /> t�FOR BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME LL cc ff TELEPHONE NUMBER <br /> -�O L 6t^ ( 0 9 J q 42..-1 q'0 � <br /> BUSINESS ADDRESS(Facility Being Inspected) 2ZIP CODE <br /> L+ O `t- O � e & � L" ,. -e--- 9S' 2-0L� <br /> FIRE DISTRICT. INSP ON DATE ARRIVAL T E DEPARTURE TIME INSPECTOR NAMFIAGENCY <br /> ck-4' 9 9/06-1 132__ L--� �-e Z 101Q- <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.Business HMMP Complete and Accurate LOO 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 ti <br /> 4. HMMP/Map Easily Accessible to Employees LIZ9.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 emergency lan <br /> EXPLANATION OF.FINDINGS AND COMMENTS <br /> D � <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 u 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(Signature) <br /> Le WHITE COPY: OES <br /> PINK COPY: BUS. <br /> 4/07 <br />