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JI in Fr. COUNTY OF SAN JOAQUIN <br />xa OFFICE OF EMERGENCY SERVICES <br />4t <br />ROOM 610, COURTHOUSE RECEIVED <br />222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 MAR 2 32005 <br />l�* e <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />FAX (209) 944-9015 SAN JOAQUINEMERGE <br />NTY <br />OFFICE OF EMERRENCY SERVICES <br />Cy SER <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />TELEPHONE NUMBER <br />c r <br />BUSINESS ADDRESS (Facility Being Inspected) <br />FIRE DISTRICT <br />INSP CTION DATERIVAL <br />TIME <br />DEPARTURE TIME <br />INSPECTION TYPE <br />r <br />I <br />(Zia <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />17. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employees <br />18. 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 />10. Plant Operations Appear Safe <br />are Hazardous Waste Manifests On Site? <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 />/ <br />' <br />13. Soil and Facility Appear Non -Contaminated f <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />� /) i Y d <br />k L 1 ,:Lia. t A it IT, <br />r <br />v Vv <br />p ` <br />\ e cy n Y wa 5 C,='�7'' _t' i,> 1n,-�... i -Y l.3r S ✓7-e,'C�" <br />REFERRALS ❑ SJ Ag ❑ SJ Env 111th ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES By <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />I <br />i /O <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTIONRESULTS , <br />Business Reentagiv (P int Name and Title) ,� <br />BuSi e,!(s epre n tive (Signature) <br />7e <br />1 <br />Name of Inspecto, Ag cy ire Co. (I Appropriate) <br />-WPY: OES <br />PINK COPY: BUSINESS <br />I REV 9/02 <br />