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p „IN <br /> S' Z <br /> n: <br /> NO 0177 88 <br /> ;t etiar+" SAN JOAQUIN COUNTY OFFICE OF EMERGENCY SERVICES <br /> HAZARDOUS MATERIAL DIVISION <br /> L (/ INSPECTION FORM <br /> INSPECTION DATE Z a ARRIVAL TIME q r DEPARTUYZE TIME_________ <br /> BUSINESS NAMEs PHONE, <br /> BUSINESS <br /> BUSINESS ADDRES _-- �p ( � h?-- -- �- ---------------- <br /> FORM TYPE: _____ <br /> SHORT _____LONG -----FARM _____ XEMF'T <br /> A. ADMINISTRATIVE INFORMATION <br /> Ye No Comments <br /> 1. Business Plan available on-site e <br /> _. Notification Information current <br /> 3. Staff Responsibilities current <br /> --- --- ------------------------ <br /> 4. Plan signed/dated _ _ ------------- <br /> 5. <br /> ----5. Evacuation Procedures posted =__ ___ ---_ <br /> 6. 1/3 Mile Land Use noted <br /> 7. Safety/Spill /Monitoring Equipment ___ <br /> G. Clean-Up Company Phone # posted ___ ___ --_ <br /> 9. Spill Containment Procedures ___ _ --- <br /> 10. Nature of Business ___ __ _ _____�j0A.1___ <br /> 11. Facility Diagram w/ Chemicals noted _ _7_� <br /> 12. Topographical Diagram ___ __- �_ _ � 7r, <br /> 13. Employee Training Records <br /> 14. Waste Generator ___ ___ <br /> 15. EPA Number for waste generators -��71 , J ?L7Z----- <br /> 16. Chemical Inventory complete eJ`PSSai4! <br /> 'i VIfA/4itS SPoft 40 <br /> B. HAZARDOUS_MATERIAL_SAFE_STORAGE_AND_HAN_LING_INFDRMATION(6,l 4/%44/{ <br /> Yeses No Comments <br /> 1 . Material Safety Data Sheets on file I// --- (J�qqqq�V c�Q��LY� _le_ <br /> Chemicals properly labelled -L ___ 1^lL <br /> _ s �J <br /> 3. Chemicals properly stored _ --- <br /> 4. Safety Hazards _IL __11j1j7�3_ Jv_ ________ <br /> 5. Housekeeping in order ________________________ <br /> 6. Secondary Containment ________________________ <br /> C. /^� yCOM LI_ANCE_VE_RIF_I_CATI_ON_ <br /> Inspector - L�_�-�J- 1LS -------------------- Date <br /> Approved yes _____no Follow-upInspection Date <br /> -- - P yU---------- <br /> Business Representative... __;-- -------- <br /> __ Title ------------ <br /> ------ ) <br /> - int <br /> ---- <br /> (signature) <br /> white - oes <br /> canary - applicant <br /> pink - file <br />