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i�°� <br /> 1 Y <br /> -K COUNTY OF SAN JOAQUIN <br /> °' OFFICE OF EMERGENCY SERVICES <br /> ti <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)9449015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> B NESS N Hk� TELEPHONE NUMBER <br /> - Z - <br /> BUSINESS ADDRESS(Facility ein Inspect ) <br /> FIRE DISTRICT INSPECTION DATE JARRIVALTIME DEPARTURE TIME JINSPTIONTYPE <br /> 1 Ui a �orn <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES 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 113. Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> i I ' <br /> Cl 1 J <br /> REFERRALS ❑SJ Ag ❑SJ Env Hith ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Correctiv ons Must be Deliv re OEESS By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACKNOWLIEDGEMENT OF REVIEW AND-RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Busin presentative( ig11 na ure) <br /> i�M,Lb 01 <br /> ame of In r A end Fire C Appropriate) ITE COPY: OFS <br /> PINK COPY: BUSINESS I REV 9/02 <br />