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COUNTY OF SAN JOAQUIN PCOBVED <br />OFFICE OF EMERGENCY SERVICES <br />2101 E. Earhart Avenue, Suite 300 <br />MAR 17 2011 <br />Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />Fax: 953-6268 SAN JOAQUIN COUNTY <br />VICE <br />(209) <br />OFFICE OF EMERGE[qCy <br />HAZARDOUS <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />Bl- -S[.\FSS NAME <br />ADDRESS (Facility Being Inspected) <br />ACCOUNT # <br />DATE (New Bus) <br />INSPEJZTI(�N DATE <br />ARRIVAL TIME <br />TIME <br />NATME <br />ISTART <br />JDEPARTURE <br />JINSPECTOR <br />RT LOPF" <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />15. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />0 <br />6. Employees Familiar with HMMP <br />3. Business HMMP Complete and Accurate <br />7. Training Records Available <br />4. Chemical Description Pages Complete and Accuratel- <br />8. Unsafe Conditions Observed (see details below) <br />EXPLANATION OF FINDINGS AND COMMENTS <br />INSPECTION FOLLOW IT INFORNL%']FION <br />Corrective Actions <br />Additional <br />To Be Submitted By: <br />Referrals Notes: <br />ACKNOWLEDGEMENT OF REVIEW .SND RECEIPT OF INSPECTION RESITTS <br />Business Fe—presentative (Prim Name and Title) <br />Business Representative (Signature) <br />WHITE COPY: OES <br />PINK COPY: BUS['\ <br />