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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> v: <br /> u?. ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> ., . HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> F—aR FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME t. nlTELEPHONE NI FIER <br /> BUSINESS ADDRESS (Facility I ein nspected) <br /> Z <br /> FIRE DISTRICT INSPECT ON DATE ARRI AL TIME DEPARTURE TIME INSPECTIPN TYPE <br /> - <br /> i O <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site j><7.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate X <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 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 /> 11 N <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> C,apwctive 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 Na e and <br /> �Title) <br /> � U \ 0. B ess R sgntative(Signal re <br /> Nam o t Agency Fire Co. (If Appropriate) WHITE COPY: OES <br /> PINK COPY: BUSINESS REV 9/02 <br />