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/F 140.9 <br /> COUNTY OF SAN JOAQUIN RECEIVED <br /> OFFICE OF EMERGENCY SERVICES FEB 2 4 2005 <br /> r ROOM 610,COURTHOUSE SAN JOAQUIN COUNTY <br /> 222 EAST WEBER AVENUE OFFICE OF EMERGENCY SERVICES <br /> STOCKTON, CALIFORNIA 95202 11 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> — FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> 5 5 <br /> BUSINESS ADDRESS (Facility Being Inspected) <br /> 3m?> Na.I wj_y l,N Cir 9 5 2-19- <br /> FIRE <br /> zFIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME 1INSPECTIONTYPE <br /> I 2-z2wS o: <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 <br /> 2. HMMP/Map Easily Accessible to Employees 8.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 <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 13. Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> Z hy) nn 'l a c s 1 s <br /> NA ve <br /> ovc M u <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 /> 3 - `f -OS <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business epr jentative(Signature) <br /> JUAN NNE <br /> Name Inspector Agency Fire Co. (Ifpropriate) WHITE COPY: OPS <br /> C YGI Iq/ L-kD PINK COPY: BUSINESS REV 9/02 <br />