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COUNTY OF SAN JOAQUIN <br /> I'4Rcpc OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> • ;.... -.�;� STOCKTON, CA 95202-2709 <br /> �rFGp BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> EJe6Jlei W11..L1 STO9.r 4k SZz ZO - t/ t/0/5/ <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> 3041 F, titM ,#/. 9.SZ/Z_ <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTOR NAMEJAGENCY <br /> ZL f� DJ /�.'OO o.vru ems/ ot5 <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.Business HMMP Complete and Accurate ✓ 6. Facility Map Complete and Accurate I 1Z <br /> 2.Chemical Description Pages Complete and Accurate 7.Chemical Inventory Complete and Accurate <br /> 3.Business Identification Page Complete and Accurate S. 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 emergency Ian <br /> EXPLANATION OFF FINDINGS AND COMMENTS <br /> 2 'T 7 — C4trM. f6frCS NOT I L/F LE 7-cO K <br /> adl o erg r/ iot_�owr�G <br /> — 2mi.W F "566 yirar 3ASClb VAA1415 , ro /0 "t_ i"�4x <br /> "Oft l TORY <br /> —4C&9MF "LACCLUC&Z" JV 170 o-wL. Max / 80 A✓4--. <br /> — TMC&C-A,SE- "100,1.aT W hSnr'' To /fi.f SAL MAN / Ito ✓ . <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 /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name�and QTitled�AW�� Business Re resentative(Signature) <br /> nn 4Z_:A6 » �/yf WHITE COPY: OPS <br /> u 0 CJ�� L . 1/f PINK COPY: BUS. <br /> 1` F �.L 1 %„ M07 <br />