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0 a <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> *41 , HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NA TELEPHONE NUMBER <br /> rlQA <br /> BUSINESS' DRESS(Fa ility ein I T <br /> ect ) <br /> FIRE DISTRICTNSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> - q-W12),30 � a.n <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business MINT/Inventory On Site X 1 7.Facility Map Complete and Accurate <br /> 2.HMW/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/H IIvT 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? 1Nj1 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 X 113.Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> UA <br /> bul -I u <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 /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Bmess Representative(Print Name and Title) Business Re sentativ (Si ature) <br /> urands <br /> N e of Ins or AgencyFire Co.(If Appropri ) WHITE COPY: OES <br /> C)PSPINK COPY: BUSINESS I REV 9/02 <br />