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COUNTY OF SAN JOAQUIN <br /> OFFICE OF SERVICES <br /> ROOM 610,COURTHOUSE MAY 17 2004 <br /> 222 EAST WEBER AVENUEt <br /> STOCKTON, CALIFORNIA 95202 F. (r`�srpi +.'S[RVICE <br /> HAZARDOUS MATERIALS DIV N.(209)468-3969 •� <br /> CPAX(209)9449015 <br /> HAZARDOUS MA Am INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> a - � 3X7- /ds-T <br /> BUSINESS AD S (Facility Being II/nspected) 1 <br /> // 5 S7o c��'7<o�t .�7 <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 70 7. Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employee 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, 40.Plant Operations Appear Safe t <br /> are Hazardous Waste Manifests On Site? 11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets(MSDS) On Site12t7tI .Hazardou arena's roperly Stored and Labeled <br /> 6.Current Training Records On Hand 13. Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> C <br /> ,y, owl i7�- c Lo QES S��z <br /> awi.¢2/c tjji W!c uue <br /> r <br /> REFERRAL ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire A ❑ <br /> INSPECTI W UP INFORMATION <br /> Correctiv Actions Must elivered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ��Zz lely <br /> ACKNOWLRPGEMENT VIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business RepresenfabTTTPrint Name and Title) Business Representative(Signature) <br /> Z'Z <br /> v <br /> Name of In for Agency Fire Co. (If Appropriate) WHITE COPY: OES REV 9/0 <br /> �l PINK COPY: BUSINESS <br />