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,� COUNTY OF SAN JOAQUIN <br /> utN <br /> x° '�o� OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> m ' 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> +YiFbd?`�• <br /> 4 TELEPHONE(209)468-3969 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> Sammi -,7-0aQcun/ �4/q 3&s-589 <br /> 90 <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIP CODE <br /> 1 211 S- Al. 1��v21Q 952ScZ <br /> FIREDISTRICT INSPECTIONDATE ARRIVAL TIME DEPARTURE TIME I INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1. Business HMMP/Inventory On Site 7. Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Emplo 8. Chemical Inventory Complete&Accurate <br /> 3.Bus ID Page/HMMP Comple Accurate 9. Employees Familiar with HMM <br /> 4.If Business is a Haz s Waste Generator, 10. Plant Operations A e <br /> are Hazardou aste Manifests On Site 11.M riel� ng Properly Handled <br /> � afety Data Sheets (MSDS)On Site ate <br /> 5. Mate rials Properly Stored and Labeled <br /> urrent Training Records On Hand 13. Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked "NO" above must be explained in this section) <br /> AAAb /S / <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag [:]SJ Env Hlth ❑OSHA Fire ❑Air Dist <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must Be Delivered To OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> Name c It WHITE COPY: OES <br /> CANARY COPY: FIRE PREVENTION REV 11/96 <br /> PINK COPY: BUSINESS <br /> OES HM 1(111N) <br />