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0 <br />171 <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />*4"�o HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />FAX (209) 9449015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />• <br />BUSINESS NAME � <br />� �� <br />TELEPHONE NUMBER <br />BUSINESS ADDRESS (Facility Being Inspected) n _ <br />q �/G✓l <br />FIRE DISTRICT IN ECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br />�1e -1- ;Y, -'*(6/16) 1 L -t <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO H <br />1. Business MMP/Inventory On Site 7. Facility Map Complete and Accurate a" <br />2. HMMP/Map Easily Accessible to Employees <br />Qf 8. 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? <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 />5 12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />lal 13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />REFERRALS ❑ SJ Ag ❑ Si Env 1 -11th ❑ OSHA ❑ Fire ❑ DA ❑ <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 />Busin s Represen alive (Print Name a Title) <br />tative ( <br />Business epresenignature) <br />Name of Inspector Agency ire Co. (If Appropriate) <br />OL, � <br />WHTIE COPY: OES <br />PINK COPY: BUSINESS <br />REV 9/02 <br />