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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 /> TELEPHONE(209)468-3969 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> ` � [ 4f' <br /> BUSINESS ADDRESS <br /> [ Facility Being Inspected) ZIPC,DDE <br /> 1 i 'A6 <br /> FIRE DISTRICT INSPEC`1`1ONDATE ARRIVAL DEPAR TIME INSPECTION <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> i.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 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, 10. Plant Operations Appear Safe ZS <br /> are Hazardous Waste Manifests On Site 11.Materials Being Properly Handled <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 /> At (vatu [=C T14.41 A,slAA k_ <br /> v� 14 <br /> 0F_ <br /> W <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 DES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Bus' • epresentative( Name and Title) ' ss Representati (Signature) <br /> Name.of Inspector and Fire Company "` WHITE PY: OES <br /> CANARY COPY:OPY: FIRE PREVENTION <br /> PINK COPY: BUSINESS REV 11/96 <br /> CES-HM 1(I Ift) <br />