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P <br />kl`"' COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES RECEIVED <br />jpyg ROOM 610, COURTHOUSE MAR 1 "/� �-w�(�" <br />4 9 222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 SAN JOAQUIN COUNTY <br />+ + OFFICE OF EMERGENCY SERVICES <br />,,,.+ • a''t�j=^ HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />^�- FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />uc as 'S,6< <br />TELEPHONE NUMBER <br />- <br />3&1- 17 <br />BUSINESS ADDRESS (Facility Being Inspected) <br />BUSINESS <br />FIRE DISTRICT <br />INSPECTION DATE <br />3 oar <br />ARRIVAL TIME <br />DEPARTURE TIME <br />1INSPECTIONTYPE, <br />+� <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />/1 <br />17. Facility Map Complete and Accurate / <br />2. HMMP/Map Easily Accessible to Employees <br />/1 <br />18. Chemical Inventory Complete and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />1 <br />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site? <br />✓ <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 />I/ <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 must be explained in this section) <br />i <br />dar <br />O£S 3 a <br />REFERRALS ❑ SJ Ag ❑ SJ Env HIth ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES By <br />2 0 s- <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKIINOWLEDGEMENTOFREVIEW AND RECEIPT OF INSPEC IOVPkSLTLTS, <br />Busi Re enta 'v <br />I�AC �' <br />( int Name and Title) B i epre' n ti a (Signature) <br />9-W <br />Name <br />ns t cy ire Co. (I Appropriate) Y: OES <br />e` �'I PINK COPY: BUSINESS <br />I REV 9102 <br />