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COUNTY OF SAN JOAQWN <br /> O.p4ulN'.0 OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> ^: < 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> BUS. (209)468-3969 FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSWE;q NAME TELEPHONE NUMBER <br /> Ked Gds ;# .38l y73- -?Y.2�0 <br /> BUSINESS ADDRESS(F cility Being Inspect ) ZIP CODE <br /> aVt,g3 �� <br /> FIRE STRICT INSPE ON ATE ARRIVAL DEPARTURE TIME INSPECTION TYPE <br /> C 3 o1 � '•5 to <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> L Business HMMP/Inventory On Site 7. Facility Map Complete and Accurate a <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, ./ l0.Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site 11.Materials Being Properly Handled <br /> 5. Material Safety Data Sheets(MSDS)On Site 112.Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand 113.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked "NO" above must be explained in this section) <br /> REFERRALS (FOR OES USE ONLY) ❑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) Business Representative( nate), <br /> �fio-e L Z .N <br /> Name of Inspector and Fir CywEI oPY: <br /> CANARY COP FIRE PREVENTION REV 11196 <br /> N/Z lLG1 Q PINK COPY: BUSINESS <br /> OES•HM 1 (9100) <br />