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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)469-3969 <br /> FAX(209)9449015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> , UC,1- -kPt u d We l( 3-2 <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> TIME INSPECTION TYPE <br /> FIRE DISTRICT IN PECTION DATE ARRIVAL TIME <br /> DEPARTURE <br /> rK M <br /> IM <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site y 7.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/BADAP Complete and Accurate 9. Employees Familiar with HMMP 3, <br /> 4.If Business is a Hazardous Waste Generator, 10.Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site? VV e11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets (MSDS)On Site 12.Hazardous Materials Properly Stared 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 /> REFERRALS ❑SJ Ag ❑SJ Env Mth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be Delivered to OES By Follow Up Inspection Date DES Inspector Name Performing Follow Up <br /> • ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Busin s Representative(Print Name and itle) Business pres �ive(Signa <br /> /C/ GL-- ~— 2 .YJ <br /> Name of Inspector Xgency Fire Co. (If Appropriate) WHITE COPY: OES <br /> gill, PINK COPY: BUSINESS I REV 9/02 <br />