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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)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility BeinInsps —'Ta <br /> l — aS tre a f <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 K 1 17.Facility Map Complete and Accurate aj <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID PageMMMP 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 D 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 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> REFERRALS ❑SJ Ag ❑ SJ Env Hlth ❑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 /> Name of In pectorW A cy Fire Co.(If Appropriate) WHITE COPY: OES <br /> ''\ f I1 11 PINK COPY: BUSINESS I REV 9/02 <br />