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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 /> it P ,� HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> w <br /> FAX(209)9449015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS N l TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility e1Ins cte ) <br /> ALAmg <br /> FIRE DISTRICT INSPECTION DATE DEPARTURETIME INSPECTI TYPEZ9-oJARRIVALT54E <br /> M M <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YFS NO FACILITY INSPECTION YES NO <br /> 1. Business HMW/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(HMNP 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 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) r n <br /> jo/^ ^ <br /> O <br /> r <br /> REFERRALS ❑SJ Ag ❑ SJ Env Mth ❑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 /> Business Representative(Print Name and Title) Business Repre tative(Signature) <br /> Name o Ins Agencyire Co.(I Appropriate) WHITE COPY: OES <br /> PINK COPY: BUSINESS REV 9/02 <br />