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,Q� N COUNTY OF SAN JOAQUIN <br />... Q �p� 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 L/ TELEPHONE NUMBER <br />5 i�c,y► d awe �/'uck 1 <br />BUSINESS ADDRESS (Facility Being Inspected) IZIP CODE <br />-"'1'J 5 1 Vj <br />FIRE DISTRICT <br />INSPECTION DATE IfARRWAL <br />TIME <br />DEPARTI-IRE11ME <br />JINSPEC R NAME/AGENCY <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 />!_ <br />4. HMMP/Map Easily Accessible to Employees <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training/Exercise Records AvailableY <br />U <br />10. Conditions noted that could increase risk of releas <br />or hinder implementation of erm enc lan <br />EXPL_1NATION OF FINDINGS AND COMMENTS <br />\a <br />Ile GL- 3 dt Gl <br />Lb <br />u, Pf <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 />Follow -Up Inspection Date <br />(if appropriate) <br />Referral Actions <br />❑ SJ Ag ❑ SJ Env Hlth ❑OSHA ❑ Fire ❑ Air Dist <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION SULTS <br />Business Representat (Prt t Name and Title) <br />�A <br />Busines eprese a' e (Sig ture) <br />WHITE COPY: OFS <br />PINK COP 107 <br />