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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAMN ; <br />TELEPHONE NUMBER <br />(A loi^ <br />BUSINESS ADDRESS$ (Facil1 Being Inspected) <br />FIRED TRICT <br />INSPECTION DATE <br />2 <br />ARRIV� TTIME <br />DEPARTURE TIME <br />JINS ECTIIO ITE <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YE NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />Al <br />7. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employees <br />8. Chemical Inventory Complete and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site? <br />10. Plant Operations Appear Safe <br />11. Hazardous Materials Being Properly Handled by Employee <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above musf be explained in this section) <br />REFERRALS ❑ SJ Ag ❑ SJ Env Mth ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES ByFollow <br />Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULT <br />Business res tiyy (int Name and e) <br />•d �//GAN <br />Busines r (Signa e) <br />Nam of <br />Agency O Fire Co. (If Appropriate) <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />FZy 9/02 <br />U <br />