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. 1 <br /> COUNTY OF SAN JOAQ AN <br /> o,au!n, OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> `�tiksa� P BUS. (209)468-3969 FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIPCODE <br /> /tis N_ v-, Y <br /> FIRE DISTRICT INSPECTION D TE ARRIVALTIME DEPARTURE TIME I INSPECTION E <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 Employees 8. Chemical Inventory Complete&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.Materials Being Properly Handled <br /> 5. Material Safety Data Sheets (MSDS)On Site 12,Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand 13. Soil and Facility Appear Non-Contaminated— <br /> COMMENTS <br /> on-ContaminatedCOMMENTS (Items marked "NO" above must be explained in this section) / <br /> 02d �Qil� <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) Z <br /> ' ess rese tiv (Signature <br /> orra 6iL o <br /> Name of Inspector and Fire Com an WHITE COPY: OEs <br /> P NR COPRY Y COPY: BUSINESS ENTION REV 11196 <br /> OES-HM I (SNO) <br />