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Division of EnvironmQM Health p { <br /> (805)781-5544 Fire 1}epart05}781-73$0 <br /> x P.O.Box 1489 2160 Santa Ba Avenue <br /> 2156 Sierra Way*San Luis Obispo,CA 93406 S-qn Ixcis Ohisno CA 91401-5240 - <br /> Del2artment of Agriculture/Measurement <br /> Standards <br /> Utilities Department•(805)78I-7215 <br /> 215566SSierraaWay Suite A*San Luis Obispo,CA 93401 ie (a05)781-5910 879 Morro Street.Sam,Luis Obispo,CA 93401 <br /> ' CERTIFIED UNIFIED PROGRAM AGENCY(CUPA) <br /> Date: 12II` 1021 HAZARDOUS MATERIALS INSPECTION FORM Esu arta <br /> Time: entry by: <br /> CODE.PROGRAM SLRVICE RESULT ACTION ACTIVITY <br /> VIOLATION CODE <br /> 1This section for agency data tracking purf <br /> poses nly ¢f. <br /> FACILITY ID NO AGENCY INSPECTION TYPE <br /> FACILITY NAME: Of DEH ❑ outline <br /> ADDRESS: <br /> El <br /> DEPT reinspection <br /> ❑ CITY FIRE ❑ Complaint <br /> ❑ CITY UTILITIES ❑ Other <br /> ' PHONE: <br /> PROGRAMS INSPECTED: ❑Business Plan ❑I1W qe erator UST ❑AGT ❑Tiered Permitting <br /> REINSPECTION REQUIRED: El NO ❑YES ❑ Business Plan ❑11W Generator ❑`UST ❑AGT ❑Tiered Permitting <br /> ERMISSION TO INSPECT:inspections may involve ohtat1img foo aphs,reviewing nd copying rec ds and determ4ging <br /> om liance with adopted codesGRANTED BY(NAME/TITLE) / - ,., _ <br /> ' 0 5" / <br /> ' <br /> YES 1V0 NIA <br /> BUSINESS PLAN �y, /Y /!./ - <br /> ❑ ❑ BPOI Business plan is complete,current,&available,during inspection(HSC§25503.5,Title 19 CCR§2729) <br /> ❑ ❑ ❑ BP02 Inventory of hazardous materials is complete(HSC§25504,Title 19 CCR§2729) <br /> ❑ ❑ �� BPO3 Site layout/facility maps are accurate(HSC§25504,Title 19 CCR§2729) <br /> TRAINING PLAN <br /> ❑ ❑ TkOl Facility has appropriate training program(Title 19 CCR,§2732&22 CCR§66265.16) <br /> ❑ ❑ ❑ TR02 Training documentation is maintained on site for current personnel(Title 19 CCR§2732& <br /> 22 CCR§66265.16) <br /> EMERGENCY RESPONSE PLAN <br /> ❑ [❑ ❑ ER01 Contingency plan is complete,updated,and maintained on site(HSC§25504,Title 19 CCR <br /> §2731&22 CCR§66265.53/54) <br /> ❑ 0 ❑ ER02 Facility is operated and maintained to prevent/minimizelmitigate fire,explosion,or release <br /> of hazardous waste to the environment. Maintains all required or appropriate equipment <br /> includin an alarm and communications system(Title 19 CCR§2731&22 CCR§66265.31- <br /> .43) <br /> COMMENTS: I <br /> J A:=PA inspection forms.doc 19-Sep-02 <br />