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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> t ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> .d STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSI SS NAME TELEPHONE NUMBER <br /> 04 X Gfo*-, 1417r/-/92/ <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> 737 1XeZ1-f ;Of' YOCye? ., C4 <br /> FIREDISTRICTINSPECTION DATE ARRIVAL TIME DEPARTURE TIME I INSPECTION TYPE <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 Employees 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/HMMP 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 Employees <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 /> /,H a <br /> REFERRALS ❑SJ Ag ❑ SJ Env Hlth ❑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 /> -as-oma <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> WK/-- <br /> Name Inspector ((�� Agency n� Fire Co. (If Appropriate) WHITE COPY: OES <br /> ���� V l4 7`7%t_.`�v'e �,� PINK COPY: BUSINESS REV 9/02 <br />