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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />Z., ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />cgr�FOR��� STOCKTON, CA 95202-2709 <br />BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />A -F,91-T 9 e) A <br />TELEPHONE NUMBER <br />00 ` 2_ - <br />BUSINESS ADDRESS (Facility Being Inspected) <br />x-32 0 S . <br />ZIPCODE <br />95 2 - <br />FIRE DIST TI <br />INSP ON ATE <br />7/9 <br />ARRIVAL TIME <br />EPART[?P.E TIME <br />INSPECTOR NAMEIAGENCY <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 />&/' <br />3. Business Identification Page Complete and Accurate <br />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 />,, / <br />1�v <br />10. Conditions noted that could increase risk of release <br />or hinder implementation of emerge clan <br />EXPLANATION OF FINDINGS AND COMMENTS <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 />2..©� <br />Follow -Up Inspection Date <br />(if appropriate) <br />Referral Actions <br />❑ SJ Ag ❑ SJ Env Hlth OSHA ❑ Fire E] Air Dist <br />El <br />ACKNOWLEDGIIMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />I %-Q% _ ma5 4/w Le'.f�� Clfi <br />Business Representative (Signature) <br />WHITE COPY: OES <br />PINK COPY: BUS. <br />aim <br />