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PCU I/y. <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> :sa ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> •' - STOCKTON, CALIFORNIA 95202 <br /> c4�%FOR;a�r TELEPHONE(209)468-3969 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINES NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS (Facility Being Inspected) ZIP CODE <br /> FIRE DISTRICT, 1NSPECITON DATE AL TIME DEPARTURE TIME INSPECI'IO TYPE <br /> S ec;kTLd 133 D 13 _�- C) V c;_�r <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 (Items marked "NO" above must be explained in this section) <br /> 5 ® l br /O o0 <br /> ctr <br /> REFERRALS (FOR OES USE ONLY) 1:1 SJ Ag E]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 of Inspector and Fire Company WHITE COPY: OES <br /> CANARY COPY: FIRE PREVENTION REV 11/96 <br /> Z� PINK COPY: BUSINESS <br /> OES-HM 1(11196) <br />