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l <br /> COUNTY OF SAN JOAQUIN <br /> Via• '�Q.coc OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> jai Fsaa;i . STOCKTON, CA 95202-2709 <br /> BUS. (209) 468-3969 FAX (209) 468-0273 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIPCODE <br /> 1^r G 6 <br /> FIRE DISTRICT INSPECTION DATE ARRNAL TIME DEPARTURE TIME INSPECTO NAMFIAGENCY <br /> -1�-� a <br /> DOCUMENT REVIEW YES NO FACILrrY WALK THROUGH YES NO <br /> 1.Business HMMP Complete and Accurate 6.Facility Map Complete and Accurate <br /> 2.Chemical Description Pages Complete and Accurate 7.Chemical Inventory Complete and Accurate <br /> 3.Business Identification Page Complete and Accurate 8.Employees Familiar with HMMP <br /> 4. HMMP/Map Easily Accessible to Employees 9.Hazardous Materials/Waste Properly Labelled <br /> 10.Conditions noted that could increase risk of releas <br /> 5.Training/Exercise Records Available <br /> or hinder implementation of emergency lan <br /> EXPLANATION OF FINDINGS AND COMMENTS <br /> W td <br /> C7 m ►'n P <br /> 0A d iA_✓ — <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 Follow-Up Inspection Date Referral Actions <br /> (if appropriate) [—]SJ Ag ❑SJ Env Hlth []OSHA Fire ❑ Air Dist <br /> Jw4 ❑ <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WHITE COPY: OES <br /> // PINK COPY: BUS. <br /> is C/ Y n. 1 4107 <br />