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COUNTY OF SAN JOAQUIl O' <br />,iiPQ411`Y Cf. <br />Y 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 />BUSII�E,SS NA7 1 c <br />°�jl e6- ✓, <br />TELEPHONE NUMBER <br />870 <br />BUSINESS ADDRESS (Fa0ity Being Inspec ed) <br />InL2ro ww e l I 4s" 3 <br />FIRE D/ISTRI T <br />INSP CTION DATE <br />/6 03 <br />ARRIVAL TIME <br />/ *,TO <br />DEPARTURE TIME <br />SO <br />JINSP CTIO TYPE/ <br />eve >CZL/ o <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION 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 and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site? <br />10. Plant Operations Appear Safe <br />11. Hazardous Materials Being Properly Handled by Employees <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />13. Soil and Facility Appear Non-Contaminated <br />COMMENTS (Items mark d " O" above must be explained in this section) <br />0.r�..> Q ✓ eSS P.O. 170x O s oc� Cko9S'L0/ <br />0.Kk 2 -O a!/ <br />/ <br />00-7 <br />s / <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hith ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions ust be Delivered to OES By <br />`Z 6 O <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNO EDGEMENT Oc REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />Jnr K ►J C_ <br />IBusiness Representative ( ature) <br />Name of Inspector gency Fire Co. (If Appropriate)f <br />I'L.Q- ��� <br />wt COPY: OES <br />COPY: BUSINESS <br />REV 9/02 <br />