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oPqu,N c COUNTY OF SAN JOAQUIN <br />?' •o� OFFICE OF EMERGENCY SERVICES <br />a 2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />Cq��FORa�P Fax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BU/SI�NESS NAME <br />/t Fig/ % N EK .2iE �YickE� <br />[ACCOUNT# <br />ADDRESS (Facility Being Inspected) <br />S�S�9S'z©7 <br />ISTART DATE (New Bus) <br />INSPECTIOND TE <br />/2 z 3 / <br />ARRIVAL TIME <br />DEPARTURE TIME <br />JINSPECTOR NAMF,, <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />5. Facility Map Complete and Accurate <br />✓ <br />2. Business Identification Page Complete & Accurate <br />6. Employees Familiar with HMMP <br />3. Business HMMP Complete and Accurate <br />�/ <br />7. Training Records Available <br />4. Chemical Description Pages Complete and Accurate <br />vz <br />18. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />tJAs3 9.,%0T MLA -3L6- . G-74✓� i4 COQy ,?a <br />,1P 7 — -FG(S/A% FSS /l/,ELS S Tb /=4� 14 C®/y ®OC ��✓J�L O',t� - <br />7-10 0eYe— <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: �' - /� <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION LTS <br />Busines epresenjative (Print Name and Title) <br />V ' <br />^l r( �/ GA %�J� <br />Business sentati a (Signature) <br />G� c <br />WHITE COPY: OES <br />PINK COPY: BUREVESS <br />4110 <br />