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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> a ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> .., STOCKTON, CA 95202-2709 <br /> "4ssar' BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> w—c// Z' 4ver Co 20 - Yo'-7 <br /> BUSINESS ADDRESS (Facility Being Inspected) ZIP CODE <br /> /l o co C.. 11.1 pct H LTJ 'Cree-cc -ro A/ SZiO <br /> FIRE DISTRICT INSPECTIONDATE ARRIVALTIME DEPARTURETPAE INIPECTORNAMFJAOENCY <br /> zL /- 23- 08'j ©c3 <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 7.Chemical Inventory Complete and Accurate <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 <br /> 10.Conditions noted that could increase risk of releas <br /> (/ <br /> or hinder implementation of ewer 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 /> El <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> PINK COPY: BUS. <br /> - A 1 4/07 <br />