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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES a� <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 />N <br />"Mss <br />T T Sc-�vi` <br />TELEPHONE NUMBER <br />BUSINESS ADD SS (Facility Being Inspected) <br />IV <br />FIRE DIS R ICT <br />INSPE ION DATE <br />ARRIV <br />DEPARTURE TIME <br />INSPECTION TYPE <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business IIMMP/Inventory On Site <br />&4r <br />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 />are Hazardous Waste Manifests On Site?11. <br />10. Plant Operations Appear Safe <br />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 />13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />I <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 />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Tide) usiness Representative (Si nature) <br />,5L) ARrzP, <br />Na of nspec r A nc Ire Co. Appr priat <br />l.� .tZ <br />W' TECOPY: OFS <br />PINK COPY: BUSINESS <br />REV 9/02 <br />