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a <br />COUNTY OF SAN JOAQUIN ECEIVE© <br />OFFICE OF EMERGENCY SERVICES MAY - 2 2005 <br />y111''' ROOM 610, COURTHOUSE q CF EOAOUIN COUNTY <br />fICE <br />222 EAST WEBER AVENUE ` MERGENCY SERVICES <br />i1 STOCKTON, CALIFORNIA 95202 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />.. l F.p..R. FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />TELEPHOII E NU ER <br />BUSINESS ADDRESS (Facility Being Inspected) <br />112—,?l il/. <br />FIRE DISTRICT <br />INSPFCTIOY DATEARRIVALfTIME <br />DEPARTURE TIME <br />INSPECTION TYPE <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YFS NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />17. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employees <br />8. Chemical Inventory Complete and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site? <br />10. Plant Operations Appear Safe <br />11. Hazardous Materials Being Properly Handled by Employee <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />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 By <br />Follow Up Inspection Date —777 <br />ES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />`tr,.S gruNa, rMoq),4A <br />Business Represent 've (Si ture) <br />NaW of InspectorAgency Fire Co. (If Appropriate) <br />WHITE COPY: OES <br />PINK COPY: BUSUVESS <br />REV 9/02 <br />