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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <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 /> BUSINESS NAME TELEPHONE NUMBER <br /> m r D c f 3676 <br /> BUSINESS ADDRESS (Facility Beino Inspected) <br /> GL IC 01.01 <br /> FIRE DISTRICT INSPEC ION DATE ARRIVAL TIME DEPAR TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventmy On Site 7.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employee cl 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 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> lti <br /> REFERRALS ❑SJ Ag ❑SJ Env HIth ❑OSHA ❑Fire ❑ DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be D livered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> -17_!/ <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RE TS <br /> Business Representative(Print Name and Title) Busmes presentative(Signature) <br /> 01 C IF M A AJAI WE <br /> Name of Inspector ()A gency ` FireCo. ( Appropriate) WHITE COPY: OES <br /> I' PINK COPY: BUSINESS REV 9/02 <br /> VN (A <br />