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COUNTY OF SAN JOAQU <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> aa... STOCKTON, CA 95202-2709 <br /> BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME <br /> Ly � TELEPHONE NUMBER <br /> t 36 -f/3U.2 <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> 11M 0- ✓ Yria h q 3e/ <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTOR NAMWAGENCY <br /> ti 2� r,� aaao �� t <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 Accurate 7.Chemical Inventory Complete and Accurate Y <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 or <br /> 5.Training/Exercise Records Available 10.Conditions noted that could increase risk of release <br /> y <br /> D or hinder implementation of emergency Ian <br /> EXPLANATION 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 DES for user name and password. <br /> INSPECTION FOLLOW-UP INFORMATION <br /> Corrective Actions Must Be Submitted By Follow-Up Inspection Date Referral Actions <br /> I El <br /> (if appropriate) SJ Ag ❑SJ Env Hith OSHA E]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 /> PINK COPY: BUS. <br /> 4107 <br />