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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> "•^ '5+�1 HAZARDOUS MATERIALS DIVISION(209)468-3969 FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAMETELEPHONE NUMBER <br /> Fi� �S <br /> BUSINESS ADDRESS (Facility Being Inspected) <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME IDEPARTURE TIME INSPECTION TYPE <br /> LAW f6 d e 9 <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/IIMMP 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 /> 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 RESULTS <br /> Business Representative(Print Name and Title) Busines Representative(Signature) <br /> res -5 l O 2 S <br /> Name of Inspector Agency . Fire Co.(If Appropriate) WHITE COPY: OES <br /> PINK COPY: BUSINESS REV 9/02 <br />