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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> y 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 NAMETELEPHONE NUMBER <br /> LAtI&M <br /> W Q0 <br /> BUSINESS ADDRESS(Facility Bein Inspect ) <br /> IItE DISTRIC II -- JINSfECTIONDATE ARRIVAL TIME DEPARTURE TIME 1INSPECTIONTYPE <br /> INSPECTION RESULTS <br /> DOCUMENTREVBEW S 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 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? 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 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Coective cti ns Must be D 'vered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACK OWLED MENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Bunn s Representative(Print Name and Title) 1jusinef qk1pres <br /> en[ative(Si ature) <br /> N e Agency 1� Fir Co.(If Appropriate) WHITE COPY: OES <br /> 0I PINK COPY: BUSINESS REV 9/02 <br />