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COUNTY OF SAN JOAQUIN <br /> o c OFFICE OF EMERGENCY SERVICES <br /> c` % ROOM 610, COURTHOUSE <br /> n: 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> BUS. (209)468-3969 FAX(209)944-9015 <br /> ,tiFOMN`' <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> I lar^ 4 <br /> BUSINESS ADDRESS(Facility Bein Inspected) ZIPCODE <br /> 96 <br /> FIRE DI I 1 O DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> rnON 20PloInp <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1. Business HMMP/Inventory On Site 7. Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8. Chemical Inventory Complete&Accurate <br /> 3.Bus ID Page/HMMP Complete and Accurate 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, 7 A 10. Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site 11.Materials Being Properly Handled <br /> 5. Material Safety Data Sheets (MSDS)On Site 12.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) �J <br /> ALI- <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag ❑SJ Env Hlth OSHA [-] Fire ❑Air Dist <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 /> Representative(Print Name and Title) Busmes epresentativ (Si a[ re) <br /> Name of Inspect and Fire Company : OEs <br /> CANARY COPY: FIRE PREVENTION REV 11/96 <br /> �1� PINK COPY: BUSINESS <br /> OES-HM1 (9/00) <br />