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r — _ COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> { ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> � QLi F•• HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> B/U�INE S NAME TELEPHONE NUMBER <br /> I e Pltcf ar e L — Z <br /> BUSINESS ADDRESS(Facility Being Inspected <br /> J(1 10 S. O� L <br /> FIRE DISTRICT15 INSPECTION ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> "0/ <br /> as" �o 06 162 <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site .Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate <br /> 3. Bus ID Page/HMMP 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? h 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 I Lr 113. Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"ab a must be ex fined in this section <br /> Soo <br /> .Gi O .er i d o c 'd 200 <br /> �}S 2- <br /> REFERRALS <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 ESI pector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RE.SUVSA <br /> Busmess jiepresentative(Print Name and Title) Busin se a Si nature) <br /> JrJ 1 v <br /> Na of Ins or/ Agency Fire Co. propriate) WHITE COPY: OES <br /> T .c-z O s PINK COPY: BUSINESS R V 9/02 <br />