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a 0 <br />-" COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />I"a j� ROOM 610, COURTHOUSE <br />l 222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />'9,'%r:..••ta)� HAZARDOUS MATERIALS DIVISION(209)468-3969 <br />FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />TELEPHONE NUMBER <br />BUSINESS ADDRESS (Facility Being Inspected) <br />4 (o cp l <br />FIRE DISTRICT <br />2-Z <br />INSPECTION DATE JARRIVAL <br />3-2/- (07 <br />TIME <br />DEPARTURE TIME <br />INSPECTION TYPE <br />!%r�t�F�cA77o►I <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />7. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Em es <br />8. Chemical Inventory Complete and Accura <br />3. Bus ID Page/HMMP Comple Accurate <br />9. Employees Familiar with HM <br />4. If Business is a Haz s Waste Generator, <br />are Hazardo rite Manifests On Site? <br />10. Plant Operations A r Safe <br />11. Hazardous erials Being Properly Handled by Employee <br />5. Mate Safety Data Sheets (MSDS) On Site <br />12. H ous Materials Properly Stored and Labeled <br />urrent Training Records On Hand <br />oil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />1 A1071 /d tom/ U/L I A/&- /S /L L <br />yti/ p�/ST.Q UC <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ 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 Title) <br />Business Representative (Signature) <br />Na mg of Inspector Agency Fire Co. (If Appropriate) <br />L�t„JG-2.L lk-c-e i 40 &F:5 <br />WHITE COPY: OES <br />I PINK COPY: BUSINESS <br />REV 9/02 <br />