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a, <br /> OUNTY OF SAN JOAQUI " ���=W��' <br /> OFFICE OF EMERGENCY SERVICES MAR 3 0 2004 <br /> ROOM 610,COURTHOUSE o „ <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> I 1 + HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 - <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> Chevron #201761 825-0174 <br /> BUSINESS ADDRESS (Facility Being Inspected) <br /> 1103 S. Main Street, Manteca, CA 95337 <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME JINSPECTIONTYPE <br /> 24 1 _ O HMMP <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 X <br /> 3. Bus ID Page/HMMP Complete and Accurate 9. Employees Familiar with HMMP X <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 Employees <br /> 5. Material Safety Data Sheets (MSDS) On Site 12.Hazardous Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand jyQj 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> REFERRALS ❑SJ Ag ❑SJ Env HIth ❑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 /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Bys' ess Repre entative(Print Name and Title) Business Represen ative(Si nature) <br /> 61 ren . h Q <br /> Nf I sped I Agency- Fir o. (If Appropriate) WHITE COPY: OES <br /> o <br /> q �Qf�, C. PINK COPY: BUSINESS REV 9/02 <br />