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'qu)N <br /> COUNTY OF SAN JOAQUI <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> W: 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> C1<jF0"p NSP BUS. (209)468-3969 FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> h'Jea-e..,e ,7 4 30/7 4179- az3y <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> $Odd N /.Fl vea- auavheu ogsa�0 <br /> FIRE DISTRICT INSPEC170NDATE ARRIVALTIME DEPARTURE TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH 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&Accurate <br /> 3.Bus ID Page/14MMP Complete and Accurate ✓ 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, ,Li. 10.Plant Operations Appear Safe -..� <br /> are Hazardous Waste Manifests On Site A /� 11.Materials Being Properly Handled <br /> 5. Material Safety Data Sheets(MSDS)On Site ✓ 12.Materials Properly Stored and Labeled t, <br /> 6.Current Training Records On Hand 1 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked "NO" above must be explained in this section) <br /> 7 - d-4r1d .°e.�i�. /�1 a.P` -/i�u,�c AK <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 OES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative( •gnature <br /> �G Sf ,G -f AP54 , a� <br /> Name,/o/ff Inspector and Fir Cpanyt G H COPY: OES <br /> ARY COP <br /> PA COPY, BUSINESS PREVENTION REV I I/9G <br /> OES-HM1 (9100) <br />