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aa�,N COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />r. z ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE �/27�q <br />STOCKTON, CA 95202-2709 <br />BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAM�, <br />IRI <br />TELEPHONE NUMBER <br />INESS ADDRESS (Facility Being Inspected/ <br />ZIP CODE <br />C - <br />FIRE DISTRICT <br />51AtG' <br />INS ON TE <br />J���%� <br />ARRIIV/A1. TIM DEPARTURE TIME INSPECTORNAME/A ENCY <br />T �O <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. Business HMMP Complete and Accurate <br />6. Facility Map Complete and Accurate <br />2. Chemical Description Pages Complete and Accurate <br />7. Chemical Inventory Complete and Accurate <br />3. Business Identification Page Complete and Accurate <br />8. Employees Familiar with HMMP <br />4. HMMP/Map Easily Accessible to Employees <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training/Exercise Records Available <br />10. Conditions noted that could increase risk of release <br />or hinder im lementation of eme=cy plan <br />EXPL'INATION OF FINDINGS AND COMMENTS <br />C.'V'ev (5 7L -?L cull'IZAlt, '�o 4-,.4 c'), <br />—ot <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 <br />X T <br />Follow -Up Inspection Date <br />(if appropriate) <br />Referral Actions <br />[—]SJ Ag [:]SJ Env Hlth OSHA [:]Fire E]Air Dist <br />El <br />CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />Business Representative (Signature) <br />WHITE COPY: OES <br />PINK COPY: 407 <br />V (J <br />