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x1 ; •. COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> '•: f�r �y+� HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME _ TELEPHONE NUMBER <br /> to/ <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> 35- <br /> ,3S pQ' �s. rczn r< S74e_16r1o., a.1 9s�6 <br /> FIRE DISTRICT INSPECTION DATE JARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION 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 and Accurate <br /> 3.Bus ID Page/HMMP 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? NM 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-\,ecsC <br /> REFERRALS ❑SJ Ag ❑SJ Env Oth ❑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 /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> w� a c A t r2'04t2 =– S •+� = <br /> Namne ofI spector Agency Fir o. If Appropriate) WHITE COPY: OES <br /> /ups^� .a fyy //�-✓� - PINK COPY: BUSINESS I REV 9/02 <br />