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;0 w COUNTY OF SAN JOAQUIN <br /> °i OFFICE OF EMERGENCY SERVICES53 <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUJINESS NAMETELEPHONE NUMBER <br /> -Lt, . r ��r m I or r <br /> BUSINESS ADDRESS (Fili[y Being Inspected) <br /> 1✓ o r• Lja.- <br /> FIRE DISTRICT SPE TION DAT ARRIVAL TIME DEPARTURE TIME INS ECTIg TYP <br /> 3 / 03 / S3S� /3S'5' �ev+'�,'Co, <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES O FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 7.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/HMMP Complete and Accurate 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, 10.Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site? 11.Hazardous Materials Being Properly Handled by Employees <br /> 5. Material Safety Data Sheets(MSDS) On Site 12.Hazardous Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand 113. Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> 2Po / <br /> r b ot 'oxi e <br /> NA / .e !Q ! C, <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be Delivered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> INIZq +4 E' IEVe>AZ <br /> Name of Insp@ctt / A y Fire Co. (If Appropriate) WHITE COPY: OPS REV 9/02 <br /> t�� 1e , L PINK COPY: BUSINESS <br />