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COUNTY OF SAN JOAQUIN <br /> o.^4�IN .c OFFICE OF EMERGENCY SERVICES <br /> s.• .o <br /> ROOM 610, COURTHOUSE <br /> ` 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> • ��i l'acn`i • BUS.(209)468-3969 FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> pT� La�.�EFi�J a/f o .�i33-Z�O <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> 03(yo /V. flc� CIS-Z40 <br /> FIRE DISTRICT' INSPECTION DATE ARRIVALTIME DEPARTURE TIME INSPECTION TYPE <br /> of 1105-15' / ZO �#/7w <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH 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&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.Materials Being Properly Handled <br /> 5. Material Safety Data Sheets(MSDS)On Site 112.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 /> AF- 77 <br /> # <br /> REFERRALS (FOR OES USE ONLY) []SJ Ag ❑SJ Env Hlth [—]OSHA ❑ Fire ❑Air Dist <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must Be Delivered To UES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RUSULTS <br /> Business Representative(Print Name and Title) Busines presen[a[• ignature) <br /> GP6&0fZS4rn r`1 <br /> Name of Inspector and Fire ompany rWHITE COPY: OES <br /> CANARY COPY: FIRE PREVENTION REV 11 996 <br /> 6[. PINK COPY: BUSINESS <br /> OES-HM 1 (9/00) <br />