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COUNTY OF SAN JOAQUIN <br />p4t4! lN,, <br />OFFICE OF EMERGENCY SERVICES <br />s� ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />TELEPHONE (209) 468-3969 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME /TELEPHONE <br />Zr c / G f e e �G I C 2 5,� <br />NUMBER <br />y- 7,? - S� <br />BUSINESS ADDRESS (Facility Being Inspected) / <br />ZIP CODE <br />FIRE DI TRIC`J <br />INSPECT IFN DA ARRIV AL TIME <br />DEPART TIME <br />INSPECTION T7' -- �i <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 />9. Employees Familiar with HMMP <br />3. Bus ID Page/HMMP Complete and Accurate <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 />l t2e 1191c, V1 ✓ e ® ti.Ct .- CL 41 : <br />r, - <br />u�c I g G <br />REFERRALS (FOR OES USE ONLY) 1:1 SJ Ag SJ Env Hlth [] OSHA 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 />✓ - u D, h v_+m C U — fY1• i <br />B mess Representative (Signature) <br />��0�/ <br />Name of Inspector and Fire Company <br />( f <br />WHITE COPY: OES <br />CANARY COPY: FIRE PREVENTION <br />PINK COPY: BUSINESS <br />REV 11/96 <br />OES - HM 1 (11196) <br />