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COUNTY OF SAN JOAQUIN <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 TELEPHONENUMBER <br /> C G� � ' S �rNt dram p1- <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIPCODE <br /> ( y 2q% nc/Ld,* A 11.hl <br /> FIRE DISTRICT INSPECTION DATE A NAL TIME DEPARTURE TIME INSPECTOR NAME!AGENCY <br /> l� 3G <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 `6 7.Chemical Inventory Complete and Accurate a <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 <br /> 5.Training/Exercise Records Available 10.Conditions noted that could increase risk of release <br /> or hinder implementation of emerRencv plan <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> to"k l( G (C <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 /> 3/ ! (if appropriate) ❑SJ Ag [—]SJ Env Hlth [_]OSHA Fire ❑ Air Dist <br /> 1 ❑ <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business R presentative(Signature) <br /> WHITE COPY: OPS <br /> ( PINK COPY: BUS. <br /> ! <br /> V..� 4/07 <br />