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a <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE 4� 12— 7A; <br />c���FORN`PSTOCKTON, CA 95202-2709 <br />BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME / <br />A Tf go 4 l _ <br />TELEPHONE NUMBER <br />T ! <br />� �tS8r- 6Z <br />BUSINESS ADDRESS (FaciliBeing Ins ted / / <br />C(v © -PioC_ko ��G� <br />ZIP C E <br />�1S 20�— �. <br />FIRE DISTRICT <br />INSPECTION DATE <br />ARR' 'A.L TIME <br />DEP`ARrI U6RE TIIviE <br />INSPECTOR NAMFJAGENCY <br />j <br />/0 Inj <br />DOCUMENT REVIEW <br />ISS 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 />5,8. 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 />A <br />g <br />10. Conditions noted that could increase risk of release <br />1_4 <br />/7 <br />or hinder implementation of emergency plan <br />EXPLANATION OF FINDINGS AND COMMENTS <br />C—C/1 <br />, <br />J01 /A- <br />7Z__ "q 7-Z- Z <br />ill 71,1 <br />14 <br />74-d !2 f -�- <br />NOTE: All HMMP documents except for the Facility Map can be created and updated on the San Joaquin Count <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 />Referral Actions <br />^ <br />(if appropriate) <br />F]SJ Ag [:]SJ Env Hlth [:]OSHA❑ Fire ❑Air Dist <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 />TG <br />PINK COPY: BUS. <br />1P <br />4/07 <br />- v <br />