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I x{7Z <br /> �F <br /> b001N COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RECEIVED <br /> 1 y� ROOM 610,COURTHOUSE <br /> :.: 222 EAST WEBER AVENUE DEC 16 2004 <br /> STOCKTON, CALIFORNIA 95202 <br /> SAN JOAQUIN COUNTY <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 OFFICE OF EMERGENCY SERVICES <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> FIRE DISTRICT 1INSPECTIONDATE ARRIVAL TIME ]DEPARTURE TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YE NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 17.Facility Map Complete and Accurate <br /> 2. HMMP[Map Easily Accessible to Employees 18. Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/HMMP Complete and Accurate9. 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 /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑ Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be Delivered to OHS 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) I Busine s Representative(Signature) <br /> aP_It,`Q Mow TP puanul <br /> Name of Inspector A cy Fire Co. (If_pp ropriate) WHITE COPY: OES <br /> 'r ����C� j �I- ���a\ 'DeoC, I PINK COPY: BUSINESS IREV 9/02 <br />