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COUNTY OF SAN JOAQUIN <br />°p�„►" ° OFFICE OF EMERGENCY SERVICES <br />Za ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE Z 8 <br />c°�iFCR`'`P STOCKTON, CA 95202-2709 <br />BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME N�A�J / % J <br />/''Lodc~lb*T <br />TELEPHONE NUMBER <br />0000 - 'C'3R-_ <br />BUSINESS ADDRESS (Facility Being Ins ted) <br />`000 C1.v1,c. �i.�v -�� -2)" F ✓' 4 , <br />ZIPCODE <br />�f `'-.l 7 (E <br />FIRE DISTRICT <br />Ti-� <br />ON DATE <br />92� <br />ARRIVAL TIME <br />`f3S <br />DEPAR TIME <br />mss_ <br />INSPECTOR NAMEIAGENCY <br />DO NT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. Business HMMP Complete and Accurate <br />_ <br />6. Facility Map Complete and Accurate <br />2. Chemical Description Pages Complete and Accurate <br />7. Chemical Inventory Complete and Accurate <br />3. Business Identification Page Complete and Accurate <br />floe <br />8. Employees Familiar with HMMP <br />4. HMMP/Map Easily Accessible to Employees <br />9. Hazardous Materials/Waste Properly <br />P Y Labelled <br />5. Training/Exercise Records Available <br />/ <br />10. Conditions noted that could increase risk of releas <br />or hinder implementation of emergency lan <br />EXPLANATION OF FIINDINGS 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 />Corre ive Actions Must Be Submitted By <br />, p <br />Follow -Up Inspection Date <br />(if appropriate) <br />Referral Actions <br />❑ SJ Ag [:]SJ Env Hlth OSHA Fire ❑ Air Dist <br />_AKN LEDGEME T OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />FWt_�' ✓ (C <br />Business Representative (Signature) <br />WHITE COPY: OES <br />PINK COPY: US <br />