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I 0 San Joaquin County Hazardous Maters 1994 Worksheet If you answer "yes" to any of the following questions, you are then required to submit the updated sections of the HMMP to OES by January 15, 1994. You can Obtain any necessary forms or plan sections from OES. Section 1: Yes No Has your business name or address changed?______ __ _________ ____ ____ ____ _ _ Have emergency notification personnel and/or telephone numbers changed?______________ _ j Section 2: Have you reassigned emergency responsibilities for employees?_ Has the nature of your business changed'? ________________________________ _ Has the Business Owner(s)or address changed? If yes, name of owner and date of change. ______ Did you forget to document your Business License number and expiration date?________ ____ Did you forget to document your Dun and Bradstreet number? If not,call (215)882-7748. _______ Did you forget to document the Propeny Owner(s),their mailing address.and Assessor Parcel number' Section 3• Have you reassigned an evacuation leader?_ _ _ Have you changed shift hours and number of employees per shift?_____ _ _ _ Have you changed evacuation routes and evacuation assembly areas?___________ _ ______ Has the area surrounding your business changed(i.e. new developments)?________________ Section 4: Have you reassigned a spill control leader?______________________________ Have you added,deleted,or changed your safety equipment,spill control equipment,or monitoring equipment?_ _ __ ______ _ __ _ ________ Have you designated or changed a clean-up company which can assist you during a hazardous materials incident?_ Have you changed your written spill and leak procedures?______________________ Section 5: Has your employee safety and training program changed?_____________ Section 6: Does your facility diagram or topographical map need to be updated?__________________ In particular,have you changed,added,or deleted storage locations for any hazardous materials?___ V-- Chemical /Chemical Inventory: Please complete any necessary Chemical Inventory Forms and the Inventory Certification Form and submit with this worksheet. Return only the original 1994 forms to OES by January 15, 1994. Copies of forms from previous years will not be ac- cepted. I declare under the penalty of perjury that the above information is accurate to the best of my knowledge. I understand that false/ inaccurate information may contribute to complications during a hazardous material incident. This declaration is made in the City of 5-To c-c,-coJ c California. ��/j \ Business Name: NK_WgtzaCSlF�2a 'fPoPERBpAaD `O�• Telephone Number:Cz9J464-52-S_J Site Address: FnO UJ- Cj1,lg:U Sr SZn -rots CA 95203 Mailing Address: SA1-t b Print Name: SAH �7t2Auco Job Title:P;7_nSo1j.sBli f'1AUA-C 2 Itespo ihte for the completion of H!dMP Signature: ,it-�A�t-c,c-c> Date: