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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RECEIVE <br /> z N <br /> ROOM 610,COURTHOUSE <br /> 9 222 EAST WEBER AVENUE <br /> DEC —5 2063 <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 $A�VaMIHtlllm 1.Y)11NPf <br /> FAX(209)944-9015 .OFEMMuNQYSER CE <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> \Q\ E • \-DID\ � CP <br /> FIRE DISTRICT INSPECTION DATE JARRIVALTIME IDEPARTURFTEVE 1INSPECTIONTYPE <br /> k-AAO_) \v\00 WkAV,P <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 Employee 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/IJMMP 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 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> V O r \ "v\VkP;& <br /> REFERRALS ❑SJ Ag ❑SJ Env Nth ❑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 /> PC <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title Business Representative(Signature) <br /> 12 ySB <br /> I PP <br /> Name of Inspector Agency Fire Co.(If Appropriate) WHITE COPY: OES <br /> t:a�5 ( Z 4_ A_G GPIJ VaAja__X10( PINK COPY: BUSINESS REV 9/0 <br />