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COUNTY OF SAN JOAQUI <br /> 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 TELEPHONE NUMBER <br /> ClerAeA <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> y <br /> FIRE DISTRICT INSPECTION DATE JAWIVALTTME IDEPARTURE TMfE INSPECTOR NAME/AGENCY <br /> (P I t,, l Z-e/Y <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.Business I-NU"Complete and Accurate e 6.Facility Map Complete and Accurate <br /> 2.Chemical Description Pages Complete and Accurate gl 7.Chemical Inventory Complete and Accurate <br /> 3.Business Identification Page Complete and Accurate a 8. Employees Familiar with HMMP d <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 releas Jj <br /> or hinder implementation of err enc lan <br /> EXPL_1NATION 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 /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) I Business Re esentative(Signature) <br /> WHITE COPY: OR <br /> PINK COPY: BUS. <br /> 4/07 <br />