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COUNTY OF SAN JOAQUIN <br /> �• a .oG OFFICE OF EMERGENCY SERVICES <br /> ?� ROOM 614, COURTHOUSE <br /> a; X 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> TELEPHONE(209)468-3969 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Befhg Inspected) ZIP CODE <br /> 11�3FV 4f-1 ffw 9S-7,3L <br /> FIRE DISTRICT f I INSPECITON DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH 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&Accurate <br /> 3.Bus ID Page/HMMP Complete and Accurate 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, n 10.Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site I Y 11.Materials Being Properly Handled <br /> 5.Material Safety Data Sheets (MSDS)On Site 12.Materials Properly 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 /> 3 f.d �1�E r br Ems.�i1 <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag ❑SJ Env Hlth []OSHA EjFire ❑Air Dist <br /> INSPECTION FOLLOW UP INFORMA'T'ION <br /> Corrective Actions Must Be Delivered To OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> CKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> usiness Representative(Print Name and Title) Busin s Representative(Signature) I <br /> r mpany WHITE COPY: OES <br /> CANARY COPY: FIRE PREVENTION REV 11196 <br /> PINK COPY: BUSINESS <br /> aes-HM 1(11195) <br />