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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 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 /> BUS SS N TELEPHONEi�ER <br /> BUSINESS ADDRESS(Facility eing Inspected) <br /> 2 F oLA g'SZ6S <br /> ERE DI TRICT INSPECT OND TE JARRIVALtfME DEPARTURE TIME INSPECTION TYPE <br /> 2! o /2 SO /Jo f HXAr o <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1.Business HMMP/Inventory On Site V1 7.Facility Map Complete and Accurate <br /> 2.HMMP/Map Easily Accessible to Employee 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID PagenIMMP Complete and Accurate 1,,l 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 wl 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 /> Corrective Actions Must be Delivered to OES Byow Up Inspection Date OES Inspector Name Performing Follow Up <br /> Foll <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Bu iness Representative(Print Name and Title Business Representative(Signature) <br /> l �Co FdIL <br /> Name ns ctor � Agency Fire Co. (If Appropriate) WHITE COPY: OES <br /> PINK COPY: BUSINESS REV 9/0 <br />