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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 />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />#1 FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NA <br />Gw11� (h t �ll/� <br />TELEPHONE NUMBER <br />BUSINESS ADDRESS (Facility Being Inspected) <br />I qx L.afh <br />FIRE DISTRICT <br />LKS Cha dP� <br />INSPEC11ON DATE <br />-� <br />ARRIV4 <br />TIME <br />DEPARTURE TIME <br />U <br />INSPECTION TYPE <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />7. Facility Map Complete and Accurate A, <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 />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site? <br />�l10. <br />Plant Operations Appear Safe <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 explained in this section) <br />m to jQf G� ✓uI r <br />REFERRALS ❑ SJ Ag ❑ SJ Env 111th ❑ OSHA ❑ Fire [IDA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Acns Must be Delivered to OES By <br />4 <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />6 /i , <br />Busi Re esent ' (Si ature) <br />Name of Inspector Agency Fire Co. (If Appropriate) <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 9/0 <br />