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COUNTY OF SAN JOAQUIN RECEIVED <br /> OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE APR 2 7 2005 <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 SAN JOAQUIN COUNTY <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 OFFICE OF EMERGENCY SERV7Ci S <br /> — FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRE Sl Facility Being Inspected) <br /> FIRE DISTRICT INSP CTION DATE JARRIVAL TIME DEPARTURE TIME 1INSPECTIONTYPE <br /> 3b <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 17.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate VL- <br /> 3.Bus ID Page/HMMP Complete and Accurate V 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 Employee <br /> 5. Material Safety Data Sheets(MSDS)On Site 12.Hazardous Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand V 1 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <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) Busin Re a en[ ve(Signature) <br /> e i <br /> e of Ins ector Agency Fire Co. (If Appropriate) ITE COPY: OES <br /> K COPY: BUSINESS"REV <br />