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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />Cq •..,..... :° Fax: (209) 953-6268 <br />�/PORN <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />ADDRESS (Facility Being Inspected) <br />,z'zz/1'if C <br />ACCOUNT # <br />8�o6 <br />START DATE (New Bus) <br />INSPECTION DATE I <br />/� <br />ARRIVAL TIME <br />�P�� <br />IDEPARTURE TIMEJINSPWTOR <br />Ya IP' - <br />N ME i <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES >0 FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />6. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />7. Presence of Non -Listed Regulated Chemicals <br />3. Business HMMP Complete and Accurate <br />8. Employees Familiar with HMMP <br />4. Chemical Description Pages Complete and Accurate <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training Records Available <br />10. Conditions that would hinder implementation of <br />Emergency Plan or increase risk of release are absent <br />f <br />r� <br />EXPLANATION OF FINDINGS AND COMMENTS <br />��'' ,_s' t8' /1si9 L�IGG ��,' �'G'���6C' lr tr"E✓ � ll !-rv.O�,E.6' <br />t3GC�,L f�iyiEiG/�$; <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: SSG p,1,El <br />Additional <br />Referrals/Notes: ^/®-41zr <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESU S <br />Business Representative (Print Name and Title) <br />L7 iE <br />Business Re tative (Si lure) <br />° 1 -- � ' Z-44 <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 12/08 <br />y y ' / V ell / <br />