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f-1 <br />COUNTY OF SAN JOAQUIN <br />r OFFICE OF EMERGENCY SERVICES <br />,4 <br />ROOM 610, COURTHOUSE <br />1 „rii 222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />TELEPHONE NUMBER <br />'Towo r ma O4-> <br />BUSINESS ADRESS (Facility Being <br />gIInspected) <br />.L V <br />FIRE DISTRICT INSPECTIO DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site Y 7. Facility Map Complete and Accurate " <br />2. HMMP/Map Easily Accessible to Employees <br />8. Chemical Inventory Complete and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />r <br />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests <br />d, <br />10. Plant Operations Appear Safe a <br />On Site? <br />11. Hazardous Materials Being Properly Handled by Employee <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explaiged in this section) <br />Pay[d' u✓�,k t/I C6t <br />%n C.O" i I <br />" # CL <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Action ust be elivered to OES By Follo p Ins ectioon�D OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) Business Representi (Signature)— <br />I r1(-6AT p+o wviA s <br />Name of Inspector ' Aen>ry Fire Co. (If Approp Late) WHITE COPY: OES <br />PINK COPY: BUSINESS REV 9/02 <br />