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�qu Uy <br /> COUNTY OF SAN JOAQUI <br /> �4�;•so OFFICE OF EMERGENCY SERVICES - <br /> ROOM 610, COURTHOUSE <br /> "! 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> ��•- :� BUS. (209)468-3969 FAX(209)9449015 <br /> GiFG.Re� <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TV EPHONE NUMBER <br /> C na eo✓ 'J' # if/// x'78 - 923 <br /> BUSINESS ADDRESS(Facility Being Ins'p"e�) ZIPCODE <br /> FIRE DISTRICT NSPECTI N DATE ARRIVAL TIME DEPARTURE TBvtE I INSPECTION TYPE <br /> 9- 9- 0�2_ /,p3/ /013 Fo14! � <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1. Business HMMP/Inventory On Site L/— 7. Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees ✓ 8. Chemical Inventory Complete&Accurate <br /> 3.Bus ID Page/HMMP Complete and Accurate t/ 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, <br /> 10.Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site N( 11.Materials Being Properly Handled <br /> 5. Material Safety Data Sheets(MSDS)On Site 12.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 /> coif P*/ <br /> >11Aue ii- <br /> i r4a iria�e a <br /> �e • a� sviiXeGu <br /> REFERRALS (FOR DES USE ONLY) SJ Ag [—]SJ Env FilthOSHA Fire ❑Air Dist <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 /> Name I Inspector and Fir ompany WHITE COPY: OES <br /> PINK COPCANARY Y BUSINESS PY: FIRE ELATION REV I I/96 <br /> OES-HM1 (&W) <br />