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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />r` 'z ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE / 2 -?C, y <br />STOCKTON, CA 95202-2709 <br />BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS AT -&-T NAME <br />! I <br />TELEPHONE NUMBER <br />0 oo —6309 ZF2Z <br />BUSINESS ADDRESS (Facility Being Inspec d) <br />ZIPCODE <br />`�S33 7 <br />FIRE DISTRICT <br />►M��-L' C.IN;rPO <br />DATE <br />�� <br />ARRIVALTIME <br />gas o <br />PARTURET1IvIE <br />/a s� <br />INSPECTOR NAME/AGENCY <br />�6 Z z o 4u <br />DOCUMENT REVIEW YES NO FACILITY WALK TffR OT TCTK YES NO <br />1. Business HMMP Complete and Accurate <br />• <br />6. Facility Map Complete and Accurate <br />2. Chemical Description Pages Complete and Accurate <br />t/ <br />7. Chemical Inventory Complete and Accurate <br />3. Business Identification Page Complete and Accurate <br />v <br />8. Employees Familiar with HMMP <br />✓ <br />4. HMMP/Map Easily Accessible to Employees <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training/Exercise Records Available <br />10. Conditions noted that could increase risk of release <br />or hinder implementation of emergency lan <br />EXPL_i,NATION OF FINDINGS AND COMMENTS <br />01 <br />C H a L 2.�ci QH h O <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 />Aacmd 19,12-oa <br />Follow -Up Inspection Date <br />(if appropriate) <br />Referral Actions <br />[:]SJ Ag [:]SJ Env Hlth❑OSHA [:]Fire❑ Air Dist <br />❑ <br />_.CKN LEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />,,) /� n t r <br />A "' Le,q �) T e( H k) <br />Business a resentative (Signature) <br />C4 t% <br />WHITE COPY: OES <br />PINK COPY: US <br />