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COUNTY OF SAN JOAQUIN <br />• PCU tN. <br />�9.�.coG OFFICE OF EMERGENCY SERVICES <br />:sa ROOM 610, COURTHOUSE <br />10: 222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />cq��FOR;a�r TELEPHONE (209) 468-3969 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAMETELEPHONE <br />e d1 C'�, • Zs� <br />NUMBER <br />1-7,?-- �� o <br />BUSINESS ADDRESS (Facility Being Inspected) <br />ass" PC- ,�'; k k� <br />ZIP CODE <br />9s2 o <br />FIRE DD1 TRICr J- <br />J C�fC Tbc2 <br />INSPECTI N DA ARRIVAL TIME <br />, �C27 <br />DEPARTURETIME <br />INS�PE/CTION Tr L. <br />�/ 2l�' i 7�` G4 Ti <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br />1. Business HMMP/Inventory On Site <br />7. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employees <br />8. Chemical Inventory Complete & Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />9. Employees Familiar with HMMP <br />10. Plant Operations Appear Safe <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site <br />11. Materials Being Properly Handled <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />C o '` <br />VL&5 o e ci v ` o !! 6 0 <br />2<n c ' <br />REFERRALS (FOR OES USE ONLY) E] SJ Ag E]SJ Env Hlth []OSHA E]Fire [] Air Dist <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) <br />c�*n.3 fYl• l <br />cJLn �- W` I► Co - <br />B iness Representative (Signature) <br />` 1 J� <br />Name of Inspector and Fire Company <br />C e,fi Z 2_ <br />WHITE COPY: OES <br />CANARY COPY: FIRE PREVENTION <br />PINK COPY: BUSINESS <br />REV 11/96 <br />OES • HM 1 (11196) <br />