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0 • <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSI S NAME TELEPHONE NUMBER <br /> Vi r e " `t�Ff _ 9ti� 2- <br /> BUSINESS/ADDRESS(Facility Being Inspected) <br /> <3S O � <br /> FIRE DISTRICTSPECT ON D TE ARRrYAL TIME DEPARTURE TIME INECTION TYPE <br /> �Z a to / 2 Z 5� / ,300 t -&/� <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site .Facility Map Complete and Accurate <br /> 2.HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate ,/ <br /> 3.Bus ID Page/IIMMP 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? IVIA <br /> d 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 113.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> - D 0120;� <br /> o•a <br /> 5 DS <br /> d /? .ex , off. X S �. s i/� a <br /> s /l <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> C tive Ac ' Must be Delivered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> E'CP_v'+�1 c- 3 t! ZD O (o <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Tide) Business Re ese alive(Signature) <br /> i�� CIt oM C.jj <br /> Nameo nsp for Agen Fire Co.(If Appropriate) WHITE COPY: OES <br /> Z PINK COPY: BUSINESS REV 9/02 <br />