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COUNTY OF SAN JOAQUIN ; <br /> OFFICE OF EMERGENCY SERVICES AUG 127 2004 <br /> ROOM 610,COURTHOUSE <br /> y a' 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 /> BUSI SS ADDRESS(Facility Being Inspected <br /> 193 Q <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> c� <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 7. Facility Map Complete and Accurate t/ <br /> 2. HMMP/Map Easily Accessible to Employees 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 1/ <br /> are Hazardous Waste Manifests On Site? '1� 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 113. Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> 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 R ULTS <br /> Business Representative(Print Name and Title) B sena[' (S' nature) <br /> Na f Ins ct Agen FireCo.-(If A o ate) WHITE : OES <br /> PINK COPY: BUSINESS I REV 9/0 <br />