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%CkV COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 2101 E. Earhart Avenue, Suite 300 <br /> Q: <br /> Stockton,California 95206 <br /> Telephone:(209)953-6200 <br /> c� .... NsP Fax:(209)953-6268 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME ADDRESS(Facility Being Inspected) <br /> Az� a zz_S /cz✓ <br /> ACCOUNT# START DATE(New Bus) INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME INSPECTOR NAME <br /> 9Coo`T y-Z3- Oct 09.30 LCT( <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1.HMMP/Map On Hand and Easily Accessible 6. Facility Map Complete and Accurate ✓ <br /> 2.Business Identification Page Complete&Accurate ✓ 7. Presence of Non-Listed Regulated Chemicals r/ <br /> 3.Business HMMP Complete and Accurate 8. Employees Familiar with HMMP ✓ <br /> 4.Chemical Description Pages Complete and Accurate ✓ 9. Hazardous Materials/Waste Properly Labelled <br /> 5.Training Records Available 10. Conditions that would hinder implementation of / <br /> Emergency Plan or increase risk of release are absent ✓ <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> 31u5l�eSs <br /> '�S ' i.�! n/e�D S To coli' O` esv/c oyes r�,finlid� <br /> TM) G/3 yr c c. !� inliJCs S1ut2tMe�l7S. <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Additional <br /> !'o Be Submitted By: ,j— 7—O`� Referrals/Notes: <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION JLESULTS <br /> Business Representative(Print Name and Title) Busines epresentative ignature) <br /> WHITE COPY: OES <br /> PINK COPY: BUSINESS <br /> vl- aev tvoa <br />