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COUNTY OF SAN JOAQU <br /> �o�. ........� <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> ���/FpRN�P• BUS. (209)468-3969 FAX(209)944-9015 <br /> BUSINESS NAME HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> ZIP CODE <br /> 3 A14_19wdoe 9S?✓z <br /> PIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPART IME I INSPECTION <br /> 0855 1 <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH 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&Accurate <br /> 3.Bus ID Page/HMMP Complete and Accurate Vi 9. Employees Familiar with HMMP Z <br /> 4.If Business is a Hazardous Waste Generator, 10. Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site 11.Materials Being Properly Handled ✓ V/'r" <br /> 5.Material Safety Data Sheets(MSDS)On Site ✓ 12.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 /> # 7 SpA /!rli 7a S,Fr Lor Aun tr.r-7 r44c 4m4#7 694,7 <br /> 8 HDD �s J901ti v <br /> 5-i 6)Z. <br /> # 12 r qu IZUWYIl s a (os b 4Aw" h u T 5 <br /> � .qv <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag [—]SJ Env Hlth ❑OSHA ❑ Fire ❑Air Dist <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must Be Delivered To OES By Follow Up Inspection Date Inspector Name Performing Follow Up <br /> 5 !3 -0 ? <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business re en[an gnature) <br /> Z-o N Cov77s PcAAll— NJ9N966✓L <br /> Name of Inspector and Fire ompany WHITE COPY: OES <br /> CANARY COPY: FIRE PREVENTION REV 11196 <br /> PINK COPY: BUSINESS <br /> OES-HM1 (9/00) <br />