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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TTEVPHONE NUMBER <br /> u W <br /> BUSINESS AD RES�IFaci ity Bein Inrted) <br /> C/J�V Gt, <br /> FIRE DISTRICT INSPECTION DAVE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 7.Facility Map Complete and Accurate <br /> 2.HMMP/Map Easily Accessible to Employees S.Chemical Inventory Complete and Accurate IJ <br /> 3.Bus ID Page/I-IMMP Complete and Accurate 9. Employees Familiar with HMMP a1 <br /> 4.If Business is a Hazardous Waste Generator, . / 10.Plant Operations Appear Safe 7� <br /> are Hazardous Waste Manifests On Site? �S 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 113.Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> Ca 4 " Je Jtknn tn <br /> REFERRALS ❑SJ Ag ❑ SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Ac tons Must be Delivered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ' �— <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RE <br /> Business Re resentative(Print Name and Title) Business Repre entativ (Si at ) <br /> Name of Inspector Agency Fire Co.(If A ropria ) ITE COPY: OPS <br /> OL C ! PINK COPY: BUSINESS REV 9/02 <br />