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p4giN COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 9i 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> �4tt.... BUS. (209)468-3969 FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME <br /> � � S \ TELEPHONE NUMBER <br /> T <br /> BUST ESS ADDRESS(Facility Being Inspected) ZIPCODE <br /> FIRE DI ICI 1INSPECHUNDAIL ARRIVAL TIME DEPARTURE TIME INSPECnONTYPE <br /> 0_411e� IO A I9 n /0 . a2- AC Lutiu� <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> L 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/HMMP Complete and Accurate L/ 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, ,,V/ 10.Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site T'I' 11.Materials Being Properly Handled <br /> 5. Material Safety Data Sheets(MSDS)On Site ✓ 12.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) /� J <br /> - <br /> REFERRALS (FOR OES USE ONLY) [—]SJ Ag ❑SJ Env Hlth OSHA Ej 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 /> 1/0- y. 0 i f0 0/ <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULIS- <br /> Business Representative(Print Name and Title) Busi epresentati Sign re) <br /> Name nspector and re Company <br /> _ ITE COPY: OES <br /> CANARY COPY: FIRE PREVENTION <br /> PINK COPY: BUSINESS REV II/96 <br /> OES-HM1 (9/00) <br />