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COUNTY OF SAN JOAQUIN <br />ppUtty OFFICE OF EMERGENCY SERVICES <br />Z' Z ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />c��iFORi'`P STOCKTON, CA 95202-2709 <br />BUS. (209) 468-3969 FAX (209) 468-0273 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME` <br />TELEPHONE NUMBER <br />AT Mo L k. —� <br />0_44- 7 4 — Wr <br />& Lw <br />BUSINESS ADDRESS (F ility Being In/spe ted) <br />lo <br />ZIPC DE <br />�% <br />xL 0 �� W , � i lv `�i /� k c-4 P <br />FIRE DI TR(/NICT`L/' <br />IN ION D fEE <br />ARRIVr L TIN1 <br />DEPARTURE TIME <br />INSPECT/OR NAMFIAGENCY <br />r <br />6 <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 />✓ <br />7. Chemical Inventory Complete and Accurate <br />3. Business Identification Page Complete and Accurate <br />8. Employees Familiar with HMMP <br />4. HMMP/Map Easily Accessible to Employees <br />t/ <br />9• Hazardous MaterialsAVaste Properly Labelled <br />5. Training/Exercise Records Available <br />f <br />. Conditions noted that could increase risk of releas <br />f <br />or hinder implementation of emergency lan <br />EXPLANATION OF FINDINGS AND COMMENTS <br />3 - Cc" ,q b °� t ,� ' a �� n uOWb ev- A a scor <br />22� - LK7 Z 9 /'s VT e /_ O,, u.20.- ; w "M <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 />Follow -Up Inspection Date <br />Referral Actions <br />(if appropriate) <br />E] SJ Ag [:] SJ Env Hlth OSHA [:] Fire [:] Air Dist <br />T <br />VVN� �� 20©g <br />1 <br />CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />Business Representative (Signature) <br />WHITE COPY: OES <br />c <br />PINK COPY: BUS. <br />4/07 <br />