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y�u,N COUNTY OF SAN JOAQUIN <br />Oo� OFFICE OF EMERGENCY SERVICES <br />a;• 2101 E. Earhart Avenue, Suite 300 <br />"' ' Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />Fax: (209) 953-6268 <br />a� PGR <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />C '' 70 7 <br />ADDRESS (Facility Being Inspected) <br />OZ.S tJ e11V Vv0, - ,e . . eO 7 <br />ACCOUNT # <br />START DATE (New Bus) <br />INSPECTION DATE <br />2 2- - /o <br />ARRIVAL TIME <br />1Y0 <br />DEPARTURE TIME <br />INSPECTOR NAME <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. HMMP/Map On Hand and Easily Accessible <br />6. Facility Map Complete and Accurate <br />2. Business Identification Page Complete & Accurate <br />7. Presence of Non -Listed Regulated Chemicals <br />I� <br />3. Business HMMP Complete and Accurate <br />8. Employees Familiar with HMMP <br />4. Chemical Description Pages Complete and Accurate <br />9. Hazardous Materials/Waste Properly Labelled <br />5. Training Records Available <br />0. Conditions that would hinder implementation Of <br />Emergency Plan or increase risk of release are absent <br />EXPLANATION OF FIN�D/INGS AND COMMENTS <br />mi.% 4_1/fT vGf7— f}T�t . <br />_ iLcZo rL� S <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: /C:> <br />Additional <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESUL <br />ame and Title) <br />Business Representative (Print Name <br />✓'< RI Gry./�C"7 �,Vi �//A/ �—ee c&f <br />Business Repres rve 'gnature) <br />�' <br />WHITE COPY: OFS <br />PINK COPY: BUSINESS <br />12/08 <br />/�4/F+'/fLjvti <br />