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�aqR c�cCOUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />c a 2101 E. Earhart Avenue, Suite 300 <br />Stockton, California 95206 <br />Telephone: (209) 953-6200 <br />C14IFU.f�N�' Fax: (209) 953-6268 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSIN SS NAME ADDRESS (Facility Being Inspected) 11 <br />a 2 YYl oPITT a w( �d �T I .. <br />ACCOUNT k START DATE (New Bus) INSP / ON DATE ARRIVALTIME DEPAR RETIME INSP�CI'OR&ME <br />6 / �t [2 �1 l/ ifJ <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 />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 />10. Conditions that would hinder implementation of <br />Emergency Plan or increase risk of release are absent <br />EXPLANATION OF FINDINGS AND COMMENTS <br />ILfC LG I%VN ✓I �G��/Na <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions <br />To Be Submitted By: <br />Additional / <br />Referrals/Notes: <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION R&SULjS <br />usine� Re reseptat' (Print Name and Title) <br />C� / <br />B2esfes' e (Signature) <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 12/08 <br />I <br />